MEDICARE: THE WRIGLEYVILLE DENTAL GROUP

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	122300000X	Dentist	019019128	IL

General Provider Information

NPI Number	:	1508023136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE WRIGLEYVILLE DENTAL GROUP

Provider Business Mailing Address
First Line	:	1353 W CORNELIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1401
Country	:	US
Telephone Number	:	773-975-6666
Fax Number	:	773-975-4051

Provider Business Practice Location Address
First Line	:	1353 W CORNELIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1401
Country	:	US
Telephone Number	:	773-975-6666
Fax Number	:	773-975-4051

Authorized Official
Title or Position	:	D.D.S./
Name	:	JOHN A BENEDETTO
Credential	:
Telephone Number	:	773-975-6666

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	05/21/2008

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