MEDICARE: JACOB CHRISTOPHER PSCHIRRER 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		IL

General Provider Information

NPI Number	:	1063550895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB CHRISTOPHER PSCHIRRER DMD

Provider Business Mailing Address
First Line	:	1710 18TH ST
Second Line	:
City	:	CHARLESTON
State	:	IL
Zip	:	61920-3607
Country	:	US
Telephone Number	:	217-345-5124
Fax Number	:	217-345-5253

Provider Business Practice Location Address
First Line	:	1710 18TH ST
Second Line	:
City	:	CHARLESTON
State	:	IL
Zip	:	61920-3607
Country	:	US
Telephone Number	:	217-345-5124
Fax Number	:	217-345-5253

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

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

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