MEDICARE: LINCOLN PARK ORAL & COSMETIC SURGERY

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)		IL

General Provider Information

NPI Number	:	1225258957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LINCOLN PARK ORAL & COSMETIC SURGERY

Provider Business Mailing Address
First Line	:	2449 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2414
Country	:	US
Telephone Number	:	773-327-2400
Fax Number	:	773-327-4759

Provider Business Practice Location Address
First Line	:	2449 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2414
Country	:	US
Telephone Number	:	773-327-2400
Fax Number	:	773-327-4759

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARVIN GREENE
Credential	:	D.D.S.
Telephone Number	:	773-327-2400

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/21/2022

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