MEDICARE: DR. BRIAN OVERMYER DDS

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	019022498	IL

General Provider Information

NPI Number	:	1174961841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN OVERMYER DDS

Provider Business Mailing Address
First Line	:	284 MEMORIAL CT
Second Line	:	SUITE A
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6231
Country	:	US
Telephone Number	:	815-477-3700
Fax Number	:

Provider Business Practice Location Address
First Line	:	284 MEMORIAL CT
Second Line	:	SUITE A
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6231
Country	:	US
Telephone Number	:	815-477-3700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2013
Last Update Date	:	06/04/2013

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