Healthcare Provider Details

I. General information

NPI: 1225478563
Provider Name (Legal Business Name): SECOND STREET DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S 2ND ST
ST CHARLES IL
60174-2812
US

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. ALAN J ACIERNO
Title or Position: OWNER
Credential: D.D.S.
Phone: 630-339-3172