MEDICARE: MIDLOTHIAN FAMILY DENTAL LTD.

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	261QD0000X	Dental Clinic/Center	019021645	IL

General Provider Information

NPI Number	:	1265947212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDLOTHIAN FAMILY DENTAL LTD.

Provider Business Mailing Address
First Line	:	1818 KELLY CT
Second Line	:
City	:	DARIEN
State	:	IL
Zip	:	60561-5600
Country	:	US
Telephone Number	:	630-926-3920
Fax Number	:

Provider Business Practice Location Address
First Line	:	4155 147TH ST
Second Line	:
City	:	MIDLOTHIAN
State	:	IL
Zip	:	60445-3368
Country	:	US
Telephone Number	:	630-926-3920
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK FRANCIS PLOSKONKA
Credential	:	DDS
Telephone Number	:	630-926-3920

Provider Enumeration Date	:	12/12/2017
Last Update Date	:	12/12/2017

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