=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023345568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGETOWN DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2009
-----------------------------------------------------
Last Update Date | 11/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7212 EDGEBROOK LN
-----------------------------------------------------
City | HANOVER PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60133-3751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-837-3700
-----------------------------------------------------
Fax | 630-837-3849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7212 EDGEBROOK LANE
-----------------------------------------------------
City | HANOVER PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60133-3751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-837-3700
-----------------------------------------------------
Fax | 630-837-3849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. KATHLEEN M HANSEN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 630-837-3700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019019366
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------