MEDICARE: DR. TRISHA ANNE FLUCKIGER 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	019031385	IL

General Provider Information

NPI Number	:	1700304631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRISHA ANNE FLUCKIGER DMD

Provider Business Mailing Address
First Line	:	1526 S BATES AVE
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-3348
Country	:	US
Telephone Number	:	217-314-9317
Fax Number	:

Provider Business Practice Location Address
First Line	:	4526 OLD SALEM LN
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-6006
Country	:	US
Telephone Number	:	217-546-8600
Fax Number	:

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

Provider Enumeration Date	:	08/30/2017
Last Update Date	:	10/23/2018

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