=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972796654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OAK LAWN DENTAL GROUP, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2007
-----------------------------------------------------
Last Update Date | 08/25/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10220 S CICERO AVE SUITE 101
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-4082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-636-0786
-----------------------------------------------------
Fax | 708-636-9389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10220 S CICERO AVE SUITE 101
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-4082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-636-0786
-----------------------------------------------------
Fax | 708-636-9389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GLENN R. SCHOENHEIDER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 708-636-0786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------