MEDICARE: DRS. NELSON AND GARY DENTAL ASSOC. LTA

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		IL
2	261QD0000X	Dental Clinic/Center		IL

General Provider Information

NPI Number	:	1467450783
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRS. NELSON AND GARY DENTAL ASSOC. LTA

Provider Business Mailing Address
First Line	:	1443 W SCHAUMBURG RD
Second Line	:	STE 102
City	:	SCHAUMBURG
State	:	IL
Zip	:	60194-4065
Country	:	US
Telephone Number	:	847-895-4510
Fax Number	:	847-895-8834

Provider Business Practice Location Address
First Line	:	1443 W SCHAUMBURG RD
Second Line	:	STE 102
City	:	SCHAUMBURG
State	:	IL
Zip	:	60194-4065
Country	:	US
Telephone Number	:	847-895-4510
Fax Number	:	847-895-8834

Authorized Official
Title or Position	:	OFFICE MANAGER CORPORATE SECRETARY
Name	:	MRS. BARBARA J NELSON
Credential	:
Telephone Number	:	842-895-4513

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	08/22/2020

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