MEDICARE: ILLINOIS DENTAL PROVIDERS (TINLEY PARK), LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
2	1223E0200X	Endodontics
3	1223G0001X	General Practice Dentistry
4	1223P0221X	Pediatric Dentistry
5	1223P0300X	Periodontics
6	1223P0700X	Prosthodontics
7	122300000X	Dentist

General Provider Information

NPI Number	:	1508837709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLINOIS DENTAL PROVIDERS (TINLEY PARK), LTD.

Provider Business Mailing Address
First Line	:	7160 DALLAS PKWY STE 400
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-7111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15909 HARLEM AVE
Second Line	:
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-1609
Country	:	US
Telephone Number	:	708-429-0915
Fax Number	:	216-584-1061

Authorized Official
Title or Position	:	MANAGER CREDENTIALING
Name	:	RACHEL NITTINGER
Credential	:
Telephone Number	:	972-755-0816

Provider Enumeration Date	:	01/27/2006
Last Update Date	:	02/05/2018

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