MEDICARE: PRIMECARE DENTAL LLC

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	019019366	IL

General Provider Information

NPI Number	:	1467789867
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMECARE DENTAL LLC

Provider Business Mailing Address
First Line	:	4239 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-4852
Country	:	US
Telephone Number	:	773-276-3360
Fax Number	:	773-276-4032

Provider Business Practice Location Address
First Line	:	4239 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-4852
Country	:	US
Telephone Number	:	773-276-3360
Fax Number	:	773-276-4032

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. KATHLEEN M HANSEN
Credential	:	D.D.S.
Telephone Number	:	773-276-3360

Provider Enumeration Date	:	11/06/2009
Last Update Date	:	11/06/2009

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Directions to “PRIMECARE DENTAL LLC ” Practice Location

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