=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366861296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HANSON & SEVANDAL DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2014
-----------------------------------------------------
Last Update Date | 04/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2570 FOXFIELD RD STE 203
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-587-4444
-----------------------------------------------------
Fax | 630-587-5811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2570 FOXFIELD RD STE 203
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60174-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-587-4444
-----------------------------------------------------
Fax | 630-587-5811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. MAUREEN SEVANDAL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 312-493-6102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 019026649
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 019.026706
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------