MEDICARE: DR. LISA M GITELSON 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	1223G0001X	General Practice Dentistry	D7623	OR

General Provider Information

NPI Number	:	1740473594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA M GITELSON DMD

Provider Business Mailing Address
First Line	:	4734 RIVER RD N
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-4536
Country	:	US
Telephone Number	:	503-463-4663
Fax Number	:

Provider Business Practice Location Address
First Line	:	4734 RIVER RD N
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-4536
Country	:	US
Telephone Number	:	503-463-4663
Fax Number	:

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

Provider Enumeration Date	:	08/24/2007
Last Update Date	:	08/24/2007

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