MEDICARE: JEFFREY WOLSZON D.D.S., LTD.

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	019-021721	IL

General Provider Information

NPI Number	:	1447663117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFREY WOLSZON D.D.S., LTD.

Provider Business Mailing Address
First Line	:	1511 W TAYLOR ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4015
Country	:	US
Telephone Number	:	312-733-1080
Fax Number	:

Provider Business Practice Location Address
First Line	:	1511 W TAYLOR ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4015
Country	:	US
Telephone Number	:	312-733-1080
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. JEFFREY S WOLSZON
Credential	:	D.D.S.
Telephone Number	:	312-733-1080

Provider Enumeration Date	:	06/10/2014
Last Update Date	:	06/10/2014

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