MEDICARE: STONEWOOD DENTAL PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1265215016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONEWOOD DENTAL PLLC

Provider Business Mailing Address
First Line	:	PO BOX 70887
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44190-0887
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1830 N RICHMOND RD
Second Line	:
City	:	MCHENRY
State	:	IL
Zip	:	60051-5416
Country	:	US
Telephone Number	:	779-704-3236
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR CREDENTIALING & ENROLLMENT
Name	:	MICHELLE JACOMINO-BARNES
Credential	:
Telephone Number	:	813-270-9497

Provider Enumeration Date	:	08/16/2023
Last Update Date	:	09/14/2023

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Directions to “STONEWOOD DENTAL PLLC ” Practice Location

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