MEDICARE: DR. MICHAEL R HESTERBERG D.M.D.

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
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	28109	OTHER	IL	BLUE SHIELD IL PROVIDER #
2	567048	OTHER	IL	UNITED CONCORIDA PROVIDER
3	133110	OTHER	IL	HEALTHLINK PROVIDER #

General Provider Information

NPI Number	:	1184611212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL R HESTERBERG D.M.D.

Provider Business Mailing Address
First Line	:	2900 FRANK SCOTT PKWY W
Second Line	:	SUITE 960
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-5000
Country	:	US
Telephone Number	:	618-233-8080
Fax Number	:	618-233-1192

Provider Business Practice Location Address
First Line	:	2900 FRANK SCOTT PKWY W
Second Line	:	SUITE 960
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-5000
Country	:	US
Telephone Number	:	618-233-8080
Fax Number	:	618-233-1192

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

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	07/17/2007

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Directions to “ DR. MICHAEL R HESTERBERG D.M.D.” Practice Location

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