MEDICARE: MT. PROSPECT DENTAL EXCELLENCE, 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	261Q00000X	Clinic/Center	19A12900	IL

General Provider Information

NPI Number	:	1952452047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT. PROSPECT DENTAL EXCELLENCE, LTD

Provider Business Mailing Address
First Line	:	1640 N. ARLINGTON HEIGHTS RD.
Second Line	:	SUITE 201
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004
Country	:	US
Telephone Number	:	847-259-1111
Fax Number	:	847-259-2222

Provider Business Practice Location Address
First Line	:	1640 N. ARLINGTON HEIGHTS RD.
Second Line	:	SUITE 201
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004
Country	:	US
Telephone Number	:	847-259-1111
Fax Number	:	847-259-2222

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. JOHN E. COSTELLO
Credential	:	D.D.S.
Telephone Number	:	847-259-1111

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	09/09/2015

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