Healthcare Provider Details

I. General information

NPI: 1285025213
Provider Name (Legal Business Name): LAWRENCE PLAZA DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 S ROSELLE RD SUITE 102
SCHAUMBURG IL
60193-5540
US

IV. Provider business mailing address

5912 W LAWRENCE AVE
CHICAGO IL
60630-3305
US

V. Phone/Fax

Practice location:
  • Phone: 630-339-3172
  • Fax: 847-339-3172
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number019027347
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number019018205
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number019016834
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number01905148
License Number StateIL

VIII. Authorized Official

Name: DR. ALAN J ACIERNO
Title or Position: MANAGER
Credential: DDS
Phone: 630-339-3172