Provider Demographics
NPI:1972904282
Name:MEADOW LAKE DENTAL LLC
Entity type:Organization
Organization Name:MEADOW LAKE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ACIERNO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-339-3172
Mailing Address - Street 1:129 S ROSELLE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-5538
Mailing Address - Country:US
Mailing Address - Phone:630-339-3172
Mailing Address - Fax:847-891-6775
Practice Address - Street 1:3941 75TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7924
Practice Address - Country:US
Practice Address - Phone:630-851-5130
Practice Address - Fax:630-851-5739
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACIERNO DENTAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-07
Last Update Date:2014-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021506305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1144341108OtherNPPES