MEDICARE: TAYLOR DENTAL CLINIC LTD

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		IL

General Provider Information

NPI Number	:	1942328752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAYLOR DENTAL CLINIC LTD

Provider Business Mailing Address
First Line	:	1145 W TAYLOR STREET
Second Line	:	FIRST FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60607
Country	:	US
Telephone Number	:	312-226-1537
Fax Number	:	312-226-1537

Provider Business Practice Location Address
First Line	:	1145 W TAYLOR STREET
Second Line	:	FIRST FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60607
Country	:	US
Telephone Number	:	312-226-1537
Fax Number	:	312-226-1537

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALAN VILLANUEVA
Credential	:	DMD
Telephone Number	:	312-226-1537

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	08/22/2020

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