MEDICARE: CHILDREN'S DENTAL WORLD, 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	1223P0221X	Pediatric Dentistry	019025818	IL

General Provider Information

NPI Number	:	1477883122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S DENTAL WORLD, LLC

Provider Business Mailing Address
First Line	:	2959 S WALLACE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2959 S WALLACE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616
Country	:	US
Telephone Number	:	312-326-5437
Fax Number	:	312-842-5338

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SAM PARK
Credential	:	DDS
Telephone Number	:	312-326-5437

Provider Enumeration Date	:	12/31/2009
Last Update Date	:	12/31/2009

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