MEDICARE: TOTAL DENTAL CENTER INC.

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	019023710	IL

General Provider Information

NPI Number	:	1548430929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOTAL DENTAL CENTER INC.

Provider Business Mailing Address
First Line	:	3342 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3310
Country	:	US
Telephone Number	:	773-463-5757
Fax Number	:	773-463-2211

Provider Business Practice Location Address
First Line	:	3342 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3310
Country	:	US
Telephone Number	:	773-463-5757
Fax Number	:	773-463-2211

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. OLIVER V. VAN
Credential	:	DDS
Telephone Number	:	773-919-5757

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	03/03/2008

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