MEDICARE: VL DENTAL CARE TWO

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

General Provider Information

NPI Number	:	1760921019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VL DENTAL CARE TWO

Provider Business Mailing Address
First Line	:	6315 NORTHWEST HWY
Second Line	:	SUITE A
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-7939
Country	:	US
Telephone Number	:	815-455-3368
Fax Number	:	815-455-3306

Provider Business Practice Location Address
First Line	:	6315 NORTHWEST HWY
Second Line	:	SUITE A
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-7939
Country	:	US
Telephone Number	:	815-455-3368
Fax Number	:	815-455-3306

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. JAMES BECKER
Credential	:
Telephone Number	:	847-358-9700

Provider Enumeration Date	:	02/20/2017
Last Update Date	:	02/20/2017

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