MEDICARE: MORTON GROVE DENTAL ASSOCIATES

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	:	1467623231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORTON GROVE DENTAL ASSOCIATES

Provider Business Mailing Address
First Line	:	9133 WAUKEGAN RD
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-2120
Country	:	US
Telephone Number	:	847-470-0001
Fax Number	:	847-470-0132

Provider Business Practice Location Address
First Line	:	9133 WAUKEGAN RD
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053-2120
Country	:	US
Telephone Number	:	847-470-0001
Fax Number	:	847-470-0132

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SHARI BERTINI
Credential	:
Telephone Number	:	847-470-0001

Provider Enumeration Date	:	03/19/2008
Last Update Date	:	03/19/2008

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