MEDICARE: DR. CHRIS IVANOFF 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	30-018768	OH

General Provider Information

NPI Number	:	1437283728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRIS IVANOFF DDS

Provider Business Mailing Address
First Line	:	25761 LORAIN RD
Second Line	:	SUITE 102
City	:	NORTH OLMSTED
State	:	OH
Zip	:	44070-3368
Country	:	US
Telephone Number	:	440-734-6436
Fax Number	:

Provider Business Practice Location Address
First Line	:	25761 LORAIN RD
Second Line	:	SUITE 102
City	:	NORTH OLMSTED
State	:	OH
Zip	:	44070-3368
Country	:	US
Telephone Number	:	440-734-6436
Fax Number	:

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

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	11/06/2009

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