MEDICARE: DR. RONALD BRIAN SERSHON D.D.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	122300000X	Dentist	6287-15	WI
2	1223G0001X	General Practice Dentistry	019018687	IL

General Provider Information

NPI Number	:	1528137064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD BRIAN SERSHON D.D.S.

Provider Business Mailing Address
First Line	:	2909 E. PARK AVE.
Second Line	:	CVCTF HSU DENTAL
City	:	CHIPPEWA FALLS
State	:	WI
Zip	:	54729
Country	:	US
Telephone Number	:	608-739-2690
Fax Number	:

Provider Business Practice Location Address
First Line	:	2909 E. PARK AVE.
Second Line	:	CVCTF HSU DENTAL
City	:	CHIPPEWA FALLS
State	:	WI
Zip	:	54729
Country	:	US
Telephone Number	:	608-739-2690
Fax Number	:

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

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	12/03/2013

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