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
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1942037221
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	:	2101 E 71ST ST STE C
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-2119
Country	:	US
Telephone Number	:	773-241-7000
Fax Number	:	773-241-7007

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	SIMONE WILSON-ADELEKE
Credential	:	MPA-PPA
Telephone Number	:	732-731-8398

Provider Enumeration Date	:	09/19/2024
Last Update Date	:	09/19/2024

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