MEDICARE: AUSTIN DENTAL CARE 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	261QD0000X	Dental Clinic/Center	060008571	IL

General Provider Information

NPI Number	:	1467624577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN DENTAL CARE PC

Provider Business Mailing Address
First Line	:	1951 E 79TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4632
Country	:	US
Telephone Number	:	773-221-4071
Fax Number	:	773-221-9602

Provider Business Practice Location Address
First Line	:	1951 E 79TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4632
Country	:	US
Telephone Number	:	773-221-4071
Fax Number	:	773-221-9602

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. JOSEPH WATSON
Credential	:	D.D.S.
Telephone Number	:	773-221-4071

Provider Enumeration Date	:	03/28/2008
Last Update Date	:	02/06/2012

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