MEDICARE: JACK S. LITZ, D.D.S., LTD.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	01912745	IN

General Provider Information

NPI Number	:	1073822490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACK S. LITZ, D.D.S., LTD.

Provider Business Mailing Address
First Line	:	6435 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-5148
Country	:	US
Telephone Number	:	773-735-2515
Fax Number	:

Provider Business Practice Location Address
First Line	:	6435 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-5148
Country	:	US
Telephone Number	:	773-735-2515
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JACK S. LITZ
Credential	:	D.D.S.
Telephone Number	:	773-735-2515

Provider Enumeration Date	:	10/04/2010
Last Update Date	:	10/04/2010

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Directions to “JACK S. LITZ, D.D.S., LTD. ” Practice Location

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