MEDICARE: DENTAL PROFESSIONALS OF ILLINOIS, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1780806034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF ILLINOIS, P.C.

Provider Business Mailing Address
First Line	:	3607 NORTH VERMILLION
Second Line	:	SUITE 4
City	:	DANVILLE
State	:	IL
Zip	:	61832
Country	:	US
Telephone Number	:	217-442-0056
Fax Number	:	217-442-6352

Provider Business Practice Location Address
First Line	:	3607 NORTH VERMILLION
Second Line	:	SUITE 4
City	:	DANVILLE
State	:	IL
Zip	:	61832
Country	:	US
Telephone Number	:	217-442-0056
Fax Number	:	217-442-6352

Authorized Official
Title or Position	:	INS COOD
Name	:	LINDSAY BEARDEN
Credential	:
Telephone Number	:	217-540-5100

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	01/08/2014

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