MEDICARE: DR. JOAN PHYLLIS GOLDSTEIN 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	19020341	IL

General Provider Information

NPI Number	:	1124195185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOAN PHYLLIS GOLDSTEIN DDS

Provider Business Mailing Address
First Line	:	55 E WASHINTON #2902
Second Line	:	COSMETIC DENTAL CENTER OF CHICAGO PC
City	:	CHICAGO
State	:	IL
Zip	:	60602
Country	:	US
Telephone Number	:	312-263-2447
Fax Number	:	312-263-2158

Provider Business Practice Location Address
First Line	:	55 E WASHINGTON
Second Line	:	#2902
City	:	CHICAGO
State	:	IL
Zip	:	60602
Country	:	US
Telephone Number	:	312-263-2447
Fax Number	:	312-263-2158

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

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	07/08/2007

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