MEDICARE: DR. ILISA BETH STERN DMD

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	1223G0001X	General Practice Dentistry	DN013323	GA

General Provider Information

NPI Number	:	1518001957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ILISA BETH STERN DMD

Provider Business Mailing Address
First Line	:	1245 WORTHINGTON HILLS DR
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-1752
Country	:	US
Telephone Number	:	770-402-3131
Fax Number	:

Provider Business Practice Location Address
First Line	:	2095 HIGHWAY 211 NW
Second Line	:	SUITE 6A
City	:	BRASELTON
State	:	GA
Zip	:	30517-3402
Country	:	US
Telephone Number	:	770-868-4288
Fax Number	:

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

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	07/08/2007

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