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NPI Code Detail

MEDICARE: PRO DENTAL IL - CHAD WISE PC

MEDICARE: PRO DENTAL IL - CHAD WISE PC
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
11223G0001XGeneral Practice Dentistry
2122300000XDentist

General Provider Information

NPI Number : 1710714233
Entity Type Code : Organization
Provider Name (Legal Business Name) : PRO DENTAL IL - CHAD WISE PC
Provider Business Mailing Address
First Line : 10 WOODBRIDGE CENTER DR STE 520
Second Line :
City : WOODBRIDGE
State : NJ
Zip : 07095-1152
Country : US
Telephone Number : 732-731-8398
Fax Number :
Provider Business Practice Location Address
First Line : 1 CHICAGO AVE
Second Line :
City : OAK PARK
State : IL
Zip : 60302-2432
Country : US
Telephone Number : 708-948-7744
Fax Number : 708-948-7846
Authorized Official
Title or Position : DIRECTOR OF CREDENTIALING
Name : MRS. SIMONE WILSON-ADELEKE
Credential : MPA-PPA
Telephone Number : 732-731-8398
Provider Enumeration Date : 09/18/2024
Last Update Date : 09/18/2024

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Directions to “PRO DENTAL IL - CHAD WISE PC ” Practice Location

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