MEDICARE: DR. JEFFREY SCOTT WOLSZON 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	019-021721	IL

General Provider Information

NPI Number	:	1659360022
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY SCOTT WOLSZON D.D.S

Provider Business Mailing Address
First Line	:	1511 W TAYLOR ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4015
Country	:	US
Telephone Number	:	312-733-1080
Fax Number	:	312-733-9773

Provider Business Practice Location Address
First Line	:	1511 W TAYLOR ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4015
Country	:	US
Telephone Number	:	312-733-1080
Fax Number	:	312-733-9773

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

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	04/11/2012

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