MEDICARE: DR. JOHN BRIAN CRISHAM D.M.D.

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	:	1609084706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN BRIAN CRISHAM D.M.D.

Provider Business Mailing Address
First Line	:	2934 S LOWDEN RD
Second Line	:
City	:	OREGON
State	:	IL
Zip	:	61061-9101
Country	:	US
Telephone Number	:	815-732-2787
Fax Number	:

Provider Business Practice Location Address
First Line	:	1307 W WASHINGTON ST
Second Line	:	SUITE 130
City	:	OREGON
State	:	IL
Zip	:	61061-1022
Country	:	US
Telephone Number	:	815-732-6911
Fax Number	:

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

Provider Enumeration Date	:	05/20/2007
Last Update Date	:	07/08/2007

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