MEDICARE: LARISA KUSHNIR DMD

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	DS040901	PA

General Provider Information

NPI Number	:	1245681832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISA KUSHNIR DMD

Provider Business Mailing Address
First Line	:	3131 WALNUT ST
Second Line	:	APT 451
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3415
Country	:	US
Telephone Number	:	727-642-7215
Fax Number	:

Provider Business Practice Location Address
First Line	:	3131 WALNUT ST
Second Line	:	APT 451
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3415
Country	:	US
Telephone Number	:	727-642-7215
Fax Number	:

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

Provider Enumeration Date	:	06/25/2016
Last Update Date	:	06/25/2016

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