MEDICARE: FANTASTIC SMILES LTD.

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	019-024294	IL

General Provider Information

NPI Number	:	1104254630
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FANTASTIC SMILES LTD.

Provider Business Mailing Address
First Line	:	250 W KENSINGTON RD
Second Line	:	SUITE 2A
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-1293
Country	:	US
Telephone Number	:	847-577-5464
Fax Number	:	847-577-5474

Provider Business Practice Location Address
First Line	:	250 W KENSINGTON RD
Second Line	:	SUITE 2A
City	:	MT PROSPECT
State	:	IL
Zip	:	60056-1293
Country	:	US
Telephone Number	:	847-577-5464
Fax Number	:	847-577-5474

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EWA KOSER
Credential	:	DDS
Telephone Number	:	847-577-5464

Provider Enumeration Date	:	10/18/2013
Last Update Date	:	10/18/2013

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