MEDICARE: PARK PLACE 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	1917894	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1821135823	OTHER	IL	NPI

General Provider Information

NPI Number	:	1316100514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK PLACE DENTAL LLC

Provider Business Mailing Address
First Line	:	7702 W NORTH AVE
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-4123
Country	:	US
Telephone Number	:	708-453-7275
Fax Number	:

Provider Business Practice Location Address
First Line	:	7702 W NORTH AVE
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-4123
Country	:	US
Telephone Number	:	708-453-7275
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ZACHARY N SOIYA
Credential	:	DDS
Telephone Number	:	630-453-7275

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	07/08/2008

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Directions to “PARK PLACE DENTAL LLC ” Practice Location

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