MEDICARE: 5 STAR FAMILY DENTAL

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	1223G0001X	General Practice Dentistry	019025070	IL

General Provider Information

NPI Number	:	1013462175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5 STAR FAMILY DENTAL

Provider Business Mailing Address
First Line	:	615 E 162ND ST
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2329
Country	:	US
Telephone Number	:	708-331-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	615 E 162ND ST
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2329
Country	:	US
Telephone Number	:	708-331-1900
Fax Number	:

Authorized Official
Title or Position	:	DENTIST / OWNER
Name	:	DR. KEVIN LLOYD FATLAND
Credential	:	DMD
Telephone Number	:	708-990-7869

Provider Enumeration Date	:	08/18/2016
Last Update Date	:	02/03/2017

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