MEDICARE: DR. LUKE GUSTAVE SISKOFF 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	D10276	MN

General Provider Information

NPI Number	:	1649339136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUKE GUSTAVE SISKOFF DDS

Provider Business Mailing Address
First Line	:	1248 PIONEER LN
Second Line	:
City	:	SHAKOPEE
State	:	MN
Zip	:	55379-3463
Country	:	US
Telephone Number	:	952-496-3456
Fax Number	:

Provider Business Practice Location Address
First Line	:	14990 GLAZIER AVE
Second Line	:	#100
City	:	APPLE VALLEY
State	:	MN
Zip	:	55124-7818
Country	:	US
Telephone Number	:	952-431-5114
Fax Number	:	952-431-3576

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

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	07/08/2007

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