MEDICARE: DR. DAVID ALLEN WURZBACH 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	1223G0001X	General Practice Dentistry	019021530	IL

General Provider Information

NPI Number	:	1417950403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID ALLEN WURZBACH DDS

Provider Business Mailing Address
First Line	:	310 BARRON BLVD
Second Line	:
City	:	GRAYSLAKE
State	:	IL
Zip	:	60030-1640
Country	:	US
Telephone Number	:	847-223-8100
Fax Number	:	847-223-8218

Provider Business Practice Location Address
First Line	:	310 BARRON BLVD
Second Line	:
City	:	GRAYSLAKE
State	:	IL
Zip	:	60030-1640
Country	:	US
Telephone Number	:	847-223-8100
Fax Number	:	847-223-8218

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	07/31/2008

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