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NPI Code Detail

MEDICARE: LIBERTYVILLE PEDIATRIC DENTISTRY

MEDICARE: LIBERTYVILLE PEDIATRIC DENTISTRY
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
1261QD0000XDental Clinic/Center

General Provider Information

NPI Number : 1043088784
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIBERTYVILLE PEDIATRIC DENTISTRY
Provider Business Mailing Address
First Line : 1870 W WINCHESTER RD STE 143
Second Line :
City : LIBERTYVILLE
State : IL
Zip : 60048-5359
Country : US
Telephone Number : 630-854-6044
Fax Number :
Provider Business Practice Location Address
First Line : 1870 W WINCHESTER RD STE 143
Second Line :
City : LIBERTYVILLE
State : IL
Zip : 60048-5359
Country : US
Telephone Number : 630-854-6044
Fax Number :
Authorized Official
Title or Position : OPERATOR
Name : BIANCA HASSOUN
Credential : DMD
Telephone Number : 630-854-6044
Provider Enumeration Date : 12/12/2023
Last Update Date : 12/12/2023

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Directions to “LIBERTYVILLE PEDIATRIC DENTISTRY ” Practice Location

Language Start Address Practice Location
These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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