MEDICARE: PREMIER DENTAL CARE P.C

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	019028601	IL

General Provider Information

NPI Number	:	1700282795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER DENTAL CARE P.C

Provider Business Mailing Address
First Line	:	2333 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-4723
Country	:	US
Telephone Number	:	630-863-8342
Fax Number	:

Provider Business Practice Location Address
First Line	:	6235 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-3304
Country	:	US
Telephone Number	:	630-863-8342
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	DR. TARIQ RIYAL
Credential	:	D.D.S, M.P.P
Telephone Number	:	630-863-8342

Provider Enumeration Date	:	11/18/2014
Last Update Date	:	11/18/2014

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