MEDICARE: DR. LEE J. CRISANTI 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		IL

General Provider Information

NPI Number	:	1689845067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEE J. CRISANTI D.D.S.

Provider Business Mailing Address
First Line	:	2959 S WALLACE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3034
Country	:	US
Telephone Number	:	312-791-0920
Fax Number	:	312-842-5338

Provider Business Practice Location Address
First Line	:	2959 S WALLACE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3034
Country	:	US
Telephone Number	:	312-791-0920
Fax Number	:	312-842-5338

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

Provider Enumeration Date	:	03/13/2008
Last Update Date	:	03/13/2008

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