MEDICARE: AUSTIN FAMILY DENTAL CENTER

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		IL

General Provider Information

NPI Number	:	1710223110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN FAMILY DENTAL CENTER

Provider Business Mailing Address
First Line	:	1532 W 99TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2174
Country	:	US
Telephone Number	:	773-233-0600
Fax Number	:	773-233-0689

Provider Business Practice Location Address
First Line	:	1532 W 99TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2174
Country	:	US
Telephone Number	:	773-233-0600
Fax Number	:	773-233-0689

Authorized Official
Title or Position	:	DENTIST
Name	:	MRS. MICHELE WATSON AUSTIN
Credential	:	DDS
Telephone Number	:	773-233-0600

Provider Enumeration Date	:	12/13/2012
Last Update Date	:	12/13/2012

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