MEDICARE: DR. DEREK JAMES BOCK D.M.D., M.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	021002219	IL

General Provider Information

NPI Number	:	1356501365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEREK JAMES BOCK D.M.D., M.S.

Provider Business Mailing Address
First Line	:	840 S WAUKEGAN RD
Second Line	:	SUITE 107
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2608
Country	:	US
Telephone Number	:	847-615-5437
Fax Number	:	847-615-2955

Provider Business Practice Location Address
First Line	:	840 S WAUKEGAN RD
Second Line	:	SUITE 107
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2608
Country	:	US
Telephone Number	:	847-615-5437
Fax Number	:	847-615-2955

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

Provider Enumeration Date	:	06/12/2008
Last Update Date	:	01/29/2009

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