MEDICARE: DR. THOMAS LOVE PRENDERGAST

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	122300000X	Dentist	019022387	IL

General Provider Information

NPI Number	:	1124124821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS LOVE PRENDERGAST

Provider Business Mailing Address
First Line	:	866 N AUBURN WOODS DR
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60067-8662
Country	:	US
Telephone Number	:	847-202-5813
Fax Number	:

Provider Business Practice Location Address
First Line	:	1394 S ROUTE 12
Second Line	:
City	:	FOX LAKE
State	:	IL
Zip	:	60020-1949
Country	:	US
Telephone Number	:	847-587-5053
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	09/19/2014

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Directions to “ DR. THOMAS LOVE PRENDERGAST ” Practice Location

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