MEDICARE: CHICAGO MALL 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	122300000X	Dentist	019.028976	IL

General Provider Information

NPI Number	:	1235507583
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO MALL DENTAL, LLC

Provider Business Mailing Address
First Line	:	7501 W CERMAK RD
Second Line	:
City	:	NORTH RIVERSIDE
State	:	IL
Zip	:	60546-1438
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7501 W CERMAK RD
Second Line	:
City	:	NORTH RIVERSIDE
State	:	IL
Zip	:	60546-1438
Country	:	US
Telephone Number	:	917-902-9515
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROSTISLAV KRASNOV
Credential	:	DDS
Telephone Number	:	917-902-9515

Provider Enumeration Date	:	09/03/2015
Last Update Date	:	09/03/2015

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Directions to “CHICAGO MALL DENTAL, LLC ” Practice Location

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