DENTAL ON 45 INC — NPI 1497165385 (Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD) in THIRD LAKE, IL)

CMS-1500 Box 24J / 33a • NPI

1497165385

Type 2 Organization (Box 32a/33a)

HIPAA NUCC Taxonomy • CMS Code

1223G0001X (CMS C5)

Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD)

Box 32 Service Location & ZIP+4

34484 N US HIGHWAY 45, SUITE C, THIRD LAKE, IL, 60030-4038

✓ 9-Digit EDI 837 ZIP+4 (60030-4038)

Practice Phone & Referral Fax

(224) 541-4066

Fax: (847) 752-8425

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1497165385 (DENTAL ON 45 INC) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

Institutional Type-2 NPI facilities enroll via CMS-855A institutional provider agreements rather than individual Order & Referring PECOS.

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1497165385` (NPI-2 Organization / Facility)
Provider / Legal Name	DENTAL ON 45 INC
Plain-English Specialty	Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD) NUCC Code: `1223G0001X` (Dentist, General Practice)
Certifying / Licensing Body	American Dental Association (ADA) / State Board of Dental Examiners
Practice Location Address	34484 N US HIGHWAY 45, SUITE C, THIRD LAKE, IL, 60030-4038
Practice Telephone / Fax	Tel: (224) 541-4066 \| Fax: (847) 752-8425
Administrative Mailing Address	34484 N US HIGHWAY 45, THIRD LAKE, IL, 60030-4038
Enumeration & Last Sync	Enumerated: 2014-05-01 \| CMS Record Updated: 2014-05-01
Authorized Official	NATALIYA KORNIYCHUK (Vice-President)

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

34484 N US HIGHWAY 45, SUITE C, THIRD LAKE, IL, 60030-4038

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Plain-English Taxonomy & CMS Crosswalk (1223G0001X)

What Does Taxonomy Code 1223G0001X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 1223G0001X translates to:
"Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD)"

CMS-1500 Medicare Specialty Crosswalk: CMS Code C5 (Dentist)
Certifying / Accrediting Authority: American Dental Association (ADA) / State Board of Dental Examiners
Clinical Scope: Routine 6-month dental checkups, toothache, dental abscess, bleeding gums (periodontitis), or wisdom tooth extraction.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (DENTAL ON 45 INC)

Typical CPT / Diagnostic Procedures:

Comprehensive Oral Evaluation, Digital Dental Radiographs & Prophylaxis
Restorative Composite Fillings, Crowns, Endodontic Root Canal & Extractions

Common Therapeutic Classes:

Amoxicillin, Metronidazole & Clindamycin (Odontogenic Infections)
Chlorhexidine Gluconate 0.12% Oral Rinse & High-Fluoride Varnish

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`1223G0001X` — Dentist, General Practice Plain English: Licensed Doctor of Dental Surgery (DDS) / Doctor of Medicine in Dentistry (DMD)	State: N/A \| License: `Verified` \| Primary: Yes (Primary)

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DENTAL ON 45 INC (NPI #1497165385)