MEDICARE: PORTAGE PARK DENTAL STUDIO

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	:	1659012920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTAGE PARK DENTAL STUDIO

Provider Business Mailing Address
First Line	:	1224 LAURA LN
Second Line	:
City	:	WOODRIDGE
State	:	IL
Zip	:	60517-5062
Country	:	US
Telephone Number	:	708-369-4076
Fax Number	:

Provider Business Practice Location Address
First Line	:	5955 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-2618
Country	:	US
Telephone Number	:	773-481-9455
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DARREN DWAYNE SIMPSON
Credential	:	DDS
Telephone Number	:	708-369-4076

Provider Enumeration Date	:	04/02/2022
Last Update Date	:	04/02/2022

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Directions to “PORTAGE PARK DENTAL STUDIO ” Practice Location

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