MEDICARE: COMPASS DENTAL OF LINCOLN SQUARE

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	019028511	IL

General Provider Information

NPI Number	:	1144693748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPASS DENTAL OF LINCOLN SQUARE

Provider Business Mailing Address
First Line	:	2334 W LAWRENCE AVE STE 215
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1036
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2334 W LAWRENCE AVE STE 215
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1036
Country	:	US
Telephone Number	:	773-561-5747
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRANDON R PRUSA
Credential	:	D.D.S.
Telephone Number	:	773-525-2011

Provider Enumeration Date	:	11/04/2015
Last Update Date	:	11/04/2015

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