MEDICARE: DARTMOOR DENTAL CLINIC LLC

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	19021132	IL

General Provider Information

NPI Number	:	1023428794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DARTMOOR DENTAL CLINIC LLC

Provider Business Mailing Address
First Line	:	129 S ROSELLE RD
Second Line	:
City	:	SCHAUMBURG
State	:	IL
Zip	:	60193-5540
Country	:	US
Telephone Number	:	630-339-3172
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 CARLEMONT DR
Second Line	:	SUITE C
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-1833
Country	:	US
Telephone Number	:	815-477-2273
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. ALAN J ACIERNO
Credential	:	DDS
Telephone Number	:	630-339-3172

Provider Enumeration Date	:	05/05/2014
Last Update Date	:	05/15/2014

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