MEDICARE: JEFFREY BERT LISSAUER 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	1223G0001X	General Practice Dentistry	7899	FL

General Provider Information

NPI Number	:	1235343054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY BERT LISSAUER D.M.D.

Provider Business Mailing Address
First Line	:	3399 WOOLBRIGHT ROAD
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-7245
Country	:	US
Telephone Number	:	561-733-4004
Fax Number	:	561-733-8182

Provider Business Practice Location Address
First Line	:	3399 W WOOLBRIGHT RD
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-7245
Country	:	US
Telephone Number	:	561-733-4004
Fax Number	:	561-733-8182

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

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	07/08/2007

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