MEDICARE: DR. MAIJA ANNE FISH D.D.S.

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	390200000X	IL
2	122300000X	Dentist	6359-15	WI

General Provider Information

NPI Number	:	1528205317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAIJA ANNE FISH D.D.S.

Provider Business Mailing Address
First Line	:	3001 6TH ST
Second Line	:	STE A
City	:	NORTH CHICAGO
State	:	IL
Zip	:	60088-2833
Country	:	US
Telephone Number	:	847-688-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 6TH ST
Second Line	:	STE A
City	:	NORTH CHICAGO
State	:	IL
Zip	:	60088-2833
Country	:	US
Telephone Number	:	847-688-2100
Fax Number	:

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

Provider Enumeration Date	:	01/15/2009
Last Update Date	:	04/15/2013

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