MEDICARE: DENTAL ASSOCIATES OF SOUTH RIDGE, P.C.

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	019028057	IL

General Provider Information

NPI Number	:	1396292884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL ASSOCIATES OF SOUTH RIDGE, P.C.

Provider Business Mailing Address
First Line	:	483 EVERGREEN DR
Second Line	:
City	:	VERNON HILLS
State	:	IL
Zip	:	60061-2907
Country	:	US
Telephone Number	:	847-625-9897
Fax Number	:

Provider Business Practice Location Address
First Line	:	6121 WASHINGTON ST
Second Line	:	#202
City	:	GURNEE
State	:	IL
Zip	:	60031-5305
Country	:	US
Telephone Number	:	847-625-9897
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PRIYADARSHINI BOINPALLY
Credential	:	DDS
Telephone Number	:	847-625-9897

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	09/01/2016

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