MEDICARE: LAWN 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	019019895	IL

General Provider Information

NPI Number	:	1790752038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAWN DENTAL CENTER

Provider Business Mailing Address
First Line	:	3113 SOUTH PULASKI
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623
Country	:	US
Telephone Number	:	773-523-0700
Fax Number	:	773-523-0702

Provider Business Practice Location Address
First Line	:	3113 SOUTH PULASKI
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623
Country	:	US
Telephone Number	:	773-523-0700
Fax Number	:	773-523-0702

Authorized Official
Title or Position	:	CO OWNER DENTIST
Name	:	CHARLES OLONO
Credential	:	DDS
Telephone Number	:	773-523-0700

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	05/05/2008

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