=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700942513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | L W HENSELMAN DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 02/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1310 SHERMER RD STE 200
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-4549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-272-2181
-----------------------------------------------------
Fax | 847-272-2390
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1310 SHERMER RD STE 200
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-4549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-272-2181
-----------------------------------------------------
Fax | 847-272-2390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. LESTER W HENSELMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 847-272-2181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019-014214
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------