MEDICARE: DR. JOSEPH BALICE 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	1223G0001X	General Practice Dentistry	019-021946	IL

General Provider Information

NPI Number	:	1578650743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH BALICE D.D.S.

Provider Business Mailing Address
First Line	:	4711 WILLOW SPRINGS RD
Second Line	:
City	:	LA GRANGE
State	:	IL
Zip	:	60525-6143
Country	:	US
Telephone Number	:	708-354-1990
Fax Number	:	708-354-2646

Provider Business Practice Location Address
First Line	:	4711 WILLOW SPRINGS RD
Second Line	:
City	:	LA GRANGE
State	:	IL
Zip	:	60525-6143
Country	:	US
Telephone Number	:	708-354-1990
Fax Number	:	708-354-2646

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

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	02/20/2023

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