=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265841480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METRO DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2014
-----------------------------------------------------
Last Update Date | 08/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2746 W FULLERTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-3059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-392-2403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1541 MARKET ST
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-4608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-392-2403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | INCHUN YANG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 224-392-2403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019025360
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------