=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598056780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOWN & COUNTRY DENTAL CARE, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2011
-----------------------------------------------------
Last Update Date | 04/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1144 LAKE STREET SUITE 213
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-1043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-383-0330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1144 LAKE STREET SUITE 213
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-1043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-383-0330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | DR. THOMAS WEGNER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 708-383-0330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 019019065
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------