MEDICARE: LAS DENTAL CENTER 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	122300000X	Dentist	019.027184	IL

General Provider Information

NPI Number	:	1588058127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAS DENTAL CENTER LTD

Provider Business Mailing Address
First Line	:	425 E IRVING PARK RD
Second Line	:
City	:	WOOD DALE
State	:	IL
Zip	:	60191-1639
Country	:	US
Telephone Number	:	630-595-2880
Fax Number	:	630-595-5992

Provider Business Practice Location Address
First Line	:	425 E IRVING PARK RD
Second Line	:
City	:	WOOD DALE
State	:	IL
Zip	:	60191-1639
Country	:	US
Telephone Number	:	630-595-2880
Fax Number	:	630-595-5992

Authorized Official
Title or Position	:	DENTIST
Name	:	AMEE SHAH
Credential	:
Telephone Number	:	630-595-2880

Provider Enumeration Date	:	03/20/2015
Last Update Date	:	03/20/2015

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