MEDICARE: BEVERLY SHORES SMILE CENTER

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		IL

General Provider Information

NPI Number	:	1467540518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEVERLY SHORES SMILE CENTER

Provider Business Mailing Address
First Line	:	10142 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-1928
Country	:	US
Telephone Number	:	773-233-3535
Fax Number	:	773-238-5713

Provider Business Practice Location Address
First Line	:	10142 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-1928
Country	:	US
Telephone Number	:	773-233-3535
Fax Number	:	773-238-5713

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. KRISTINE KOWALSKI
Credential	:
Telephone Number	:	773-233-3535

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	08/22/2020

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