MEDICARE: MUNDELEIN DENTAL CLINIC 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1336655950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MUNDELEIN DENTAL CLINIC LLC

Provider Business Mailing Address
First Line	:	3074 W IL ROUTE 60
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4270
Country	:	US
Telephone Number	:	847-970-7070
Fax Number	:

Provider Business Practice Location Address
First Line	:	3074 W IL ROUTE 60
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-4270
Country	:	US
Telephone Number	:	847-970-7070
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CORPORATE OPERATIONS
Name	:	IVANA BUENO
Credential	:
Telephone Number	:	773-798-9382

Provider Enumeration Date	:	12/19/2017
Last Update Date	:	01/22/2026

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