MEDICARE: METRO 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	019025360	IL

General Provider Information

NPI Number	:	1265841480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METRO DENTAL LLC

Provider Business Mailing Address
First Line	:	1541 MARKET ST
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60016-4608
Country	:	US
Telephone Number	:	224-392-2403
Fax Number	:

Provider Business Practice Location Address
First Line	:	2746 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3059
Country	:	US
Telephone Number	:	224-392-2403
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	INCHUN YANG
Credential	:	DDS
Telephone Number	:	224-392-2403

Provider Enumeration Date	:	08/13/2014
Last Update Date	:	08/13/2014

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Directions to “METRO DENTAL LLC ” Practice Location

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