MEDICARE: DR. MARK JOHN KOLLER DDS

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		IL

General Provider Information

NPI Number	:	1841357522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK JOHN KOLLER DDS

Provider Business Mailing Address
First Line	:	1606 W CAMPBELL ST
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1516
Country	:	US
Telephone Number	:	847-255-8439
Fax Number	:	847-255-7664

Provider Business Practice Location Address
First Line	:	1606 W CAMPBELL ST
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1516
Country	:	US
Telephone Number	:	847-255-8439
Fax Number	:	847-255-8770

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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