MEDICARE: CEDAR LAKE DENTAL, 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	019027730	IL

General Provider Information

NPI Number	:	1710350152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR LAKE DENTAL, P.C.

Provider Business Mailing Address
First Line	:	1849 S CEDAR LAKE RD
Second Line	:
City	:	ROUND LAKE
State	:	IL
Zip	:	60073-5711
Country	:	US
Telephone Number	:	847-201-1102
Fax Number	:

Provider Business Practice Location Address
First Line	:	1849 S CEDAR LAKE RD
Second Line	:
City	:	ROUND LAKE
State	:	IL
Zip	:	60073-5711
Country	:	US
Telephone Number	:	847-201-1102
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MAUREEN COPELAND
Credential	:
Telephone Number	:	847-201-1102

Provider Enumeration Date	:	11/06/2015
Last Update Date	:	11/06/2015

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