MEDICARE: CENTENNIAL DENTAL GROUP LTD

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1578448536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTENNIAL DENTAL GROUP LTD

Provider Business Mailing Address
First Line	:	19524 MAGGIES WAY
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-8353
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2746 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3059
Country	:	US
Telephone Number	:	954-536-4810
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	ERIC YOUNG
Credential	:	DDS
Telephone Number	:	954-536-4810

Provider Enumeration Date	:	08/08/2025
Last Update Date	:	08/08/2025

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