MEDICARE: WINTHROP HARBOR DENTAL CENTER

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	019015026	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TRI-CARE	OTHER	IL	603323
2	BCBS OF IL	OTHER	IL	80006341
3	UNITED CONCORDIA	OTHER	IL	603323

General Provider Information

NPI Number	:	1306853429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WINTHROP HARBOR DENTAL CENTER

Provider Business Mailing Address
First Line	:	644 SHERIDAN RD
Second Line	:	SUITE 105
City	:	WINTHROP HARBOR
State	:	IL
Zip	:	60096-1350
Country	:	US
Telephone Number	:	847-872-5626
Fax Number	:	847-746-2900

Provider Business Practice Location Address
First Line	:	644 SHERIDAN RD
Second Line	:	SUITE 105
City	:	WINTHROP HARBOR
State	:	IL
Zip	:	60096-1350
Country	:	US
Telephone Number	:	847-872-5626
Fax Number	:	847-746-2900

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MRS. MICHELLE L OPELT
Credential	:
Telephone Number	:	847-872-5626

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	11/28/2011

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