MEDICARE: FAMILIA DENTAL ESL LLC

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	019026920	IL
2	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1962792747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILIA DENTAL ESL LLC

Provider Business Mailing Address
First Line	:	2050 EAST ALGONQUIN ROAD
Second Line	:	SUITE 610
City	:	SCHAUMBURG
State	:	IL
Zip	:	60173-4166
Country	:	US
Telephone Number	:	847-453-7396
Fax Number	:	847-453-7396

Provider Business Practice Location Address
First Line	:	2608 STATE ST.
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62205-2325
Country	:	US
Telephone Number	:	618-857-2300
Fax Number	:	618-857-2302

Authorized Official
Title or Position	:	CREDENTIALING & PAYER RELATIONS MAN
Name	:	MR. BRANDON ALEXANDER TAYLOR
Credential	:	CPCS
Telephone Number	:	847-453-7396

Provider Enumeration Date	:	04/13/2011
Last Update Date	:	06/25/2021

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Directions to “FAMILIA DENTAL ESL LLC ” Practice Location

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