MEDICARE: DR. JEFFREY BLANKSHAIN 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		IL

General Provider Information

NPI Number	:	1477744043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY BLANKSHAIN DDS

Provider Business Mailing Address
First Line	:	7020 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60707-4306
Country	:	US
Telephone Number	:	773-745-5555
Fax Number	:	778-745-8385

Provider Business Practice Location Address
First Line	:	7020 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60707-4306
Country	:	US
Telephone Number	:	773-745-5555
Fax Number	:	778-745-8385

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

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

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