MEDICARE: ELITE CARE DENTAL, 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	122300000X	Dentist	019-026564	IL

General Provider Information

NPI Number	:	1003143017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE CARE DENTAL, P.C.

Provider Business Mailing Address
First Line	:	16111 LA SALLE ST
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2064
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16111 LA SALLE ST
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2064
Country	:	US
Telephone Number	:	708-339-9999
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	SHAFAQ MUSTAFA
Credential	:
Telephone Number	:	708-339-9999

Provider Enumeration Date	:	11/11/2009
Last Update Date	:	11/11/2009

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