MEDICARE: DR. LARRY ALAN FISHER 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	019-015484	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639160658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY ALAN FISHER D.D.S.

Provider Business Mailing Address
First Line	:	1945 W WILSON AVE
Second Line	:	SUITE 2112
City	:	CHICAGO
State	:	IL
Zip	:	60640-5255
Country	:	US
Telephone Number	:	773-561-4508
Fax Number	:	773-561-4508

Provider Business Practice Location Address
First Line	:	1945 W WILSON AVE
Second Line	:	SUITE 2112
City	:	CHICAGO
State	:	IL
Zip	:	60640-5255
Country	:	US
Telephone Number	:	773-561-4508
Fax Number	:	773-561-4508

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	08/28/2008

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