MEDICARE: LAKE COOK DENTAL CENTER P C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	019025184	IL

General Provider Information

NPI Number	:	1003085465
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE COOK DENTAL CENTER P C

Provider Business Mailing Address
First Line	:	1207 MCHENRY RD
Second Line	:	SUITE 215
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-1371
Country	:	US
Telephone Number	:	847-955-2331
Fax Number	:

Provider Business Practice Location Address
First Line	:	1207 MCHENRY ROAD
Second Line	:	SUITE 215
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-1371
Country	:	US
Telephone Number	:	847-955-2331
Fax Number	:	847-955-2332

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROSANNA MIRANDA LESNIAK
Credential	:	D.D.S.
Telephone Number	:	847-955-2331

Provider Enumeration Date	:	02/29/2008
Last Update Date	:	06/06/2012

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