MEDICARE: DR. MARY ELIZABETH DI LISIO DMD

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	019032708	IL

General Provider Information

NPI Number	:	1710504097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ELIZABETH DI LISIO DMD

Provider Business Mailing Address
First Line	:	618 SAINT LOUIS ST
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-1504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	618 SAINT LOUIS ST
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-1504
Country	:	US
Telephone Number	:	618-656-7111
Fax Number	:

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

Provider Enumeration Date	:	07/02/2020
Last Update Date	:	07/02/2020

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