MEDICARE: EP DENTAL SLEEP MEDICINE, PLLC

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	122300000X	Dentist	23551	TX

General Provider Information

NPI Number	:	1114407970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EP DENTAL SLEEP MEDICINE, PLLC

Provider Business Mailing Address
First Line	:	11825 STATE ROUTE 40 STE 100
Second Line	:
City	:	DUNLAP
State	:	IL
Zip	:	61525-8842
Country	:	US
Telephone Number	:	309-839-9971
Fax Number	:

Provider Business Practice Location Address
First Line	:	6901 HELEN OF TROY STE D2
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79911-3130
Country	:	US
Telephone Number	:	815-881-9898
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRYAN KALISH
Credential	:	DDS
Telephone Number	:	915-881-9898

Provider Enumeration Date	:	08/20/2018
Last Update Date	:	06/12/2019

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