MEDICARE: WICKER PARK 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	261QD0000X	Dental Clinic/Center	019016946	IL

General Provider Information

NPI Number	:	1326349770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WICKER PARK DENTAL LLC

Provider Business Mailing Address
First Line	:	1738 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2147
Country	:	US
Telephone Number	:	773-276-5566
Fax Number	:	773-276-8780

Provider Business Practice Location Address
First Line	:	1738 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2147
Country	:	US
Telephone Number	:	773-276-5566
Fax Number	:	773-276-8780

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SUSAN STUART BROWN
Credential	:
Telephone Number	:	773-276-5566

Provider Enumeration Date	:	11/16/2010
Last Update Date	:	11/16/2010

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Directions to “WICKER PARK DENTAL LLC ” Practice Location

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