MEDICARE: DR. MICHAEL LEONARD SIWEK 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		IL

General Provider Information

NPI Number	:	1073557732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL LEONARD SIWEK D.D.S

Provider Business Mailing Address
First Line	:	8 S 153 MADISON ST.
Second Line	:
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-5553
Country	:	US
Telephone Number	:	630-321-1055
Fax Number	:	708-453-0580

Provider Business Practice Location Address
First Line	:	8368 GRAND AVE
Second Line	:
City	:	RIVER GROVE
State	:	IL
Zip	:	60171-1435
Country	:	US
Telephone Number	:	708-453-0500
Fax Number	:	708-453-0580

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

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	07/08/2007

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