Healthcare Provider Details

I. General information

NPI: 1316321524
Provider Name (Legal Business Name): MAIN STREET DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MAIN STREET NW
BOURBONNAIS IL
60914
US

IV. Provider business mailing address

129 S. ROSELLE RD STE. 102
SCHAUMBURG IL
60193
US

V. Phone/Fax

Practice location:
  • Phone: 815-932-3516
  • Fax:
Mailing address:
  • Phone: 630-339-3172
  • Fax: 847-891-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: DR. ALAN M. ACIERNO
Title or Position: CHIEF FINANCIAL OFFICER
Credential: DDS
Phone: 630-339-3172