MEDICARE: MYRA M LUSSMAN 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	1223P0221X	Pediatric Dentistry	7920	IA

General Provider Information

NPI Number	:	1821054487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYRA M LUSSMAN DDS

Provider Business Mailing Address
First Line	:	4090 WESTOWN PKWY
Second Line	:	SUIT B
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-6760
Country	:	US
Telephone Number	:	515-267-0737
Fax Number	:	515-267-1480

Provider Business Practice Location Address
First Line	:	4090 WESTOWN PKWY
Second Line	:	SUIT B
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-6760
Country	:	US
Telephone Number	:	515-267-0737
Fax Number	:	515-267-1480

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

Provider Enumeration Date	:	04/24/2006
Last Update Date	:	07/08/2007

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