MEDICARE: HARLEM IRVING FAMILY DENTAL, 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	261QD0000X	Dental Clinic/Center	19017598	IL

General Provider Information

NPI Number	:	1104302439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HARLEM IRVING FAMILY DENTAL, LLC

Provider Business Mailing Address
First Line	:	1699 E WOODFIELD RD
Second Line	:
City	:	SCHAUMBURG
State	:	IL
Zip	:	60173-4947
Country	:	US
Telephone Number	:	630-689-5857
Fax Number	:

Provider Business Practice Location Address
First Line	:	7601 W IRVING PARK RD STE 102
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2140
Country	:	US
Telephone Number	:	773-589-9220
Fax Number	:

Authorized Official
Title or Position	:	INSURANCE MANAGER
Name	:	KRISTY WOLTER
Credential	:
Telephone Number	:	630-869-5857

Provider Enumeration Date	:	07/19/2018
Last Update Date	:	07/19/2018

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