=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295254589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST AURORA FAMILY DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2017
-----------------------------------------------------
Last Update Date | 09/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1940 W GALENA BLVD STE 7
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60506-4482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-339-3172
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1699 E WOODFIELD RD STE 102
-----------------------------------------------------
City | SCHAUMBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60173-4955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-339-3172
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. ALAN J ACIERNO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 630-339-3172
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019029852
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019025570
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019026827
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019031185
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------