MEDICARE: DENTAL PROFESSIONALS OF ILLINOIS, PC

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	:	1427428200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF ILLINOIS, PC

Provider Business Mailing Address
First Line	:	418 E ROLLINS RD
Second Line	:
City	:	ROUND LAKE BEACH
State	:	IL
Zip	:	60073-1334
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	418 E ROLLINS RD
Second Line	:
City	:	ROUND LAKE BEACH
State	:	IL
Zip	:	60073-1334
Country	:	US
Telephone Number	:	847-752-0990
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	KENDRA WALKER
Credential	:
Telephone Number	:	217-540-8312

Provider Enumeration Date	:	10/06/2015
Last Update Date	:	10/06/2015

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