MEDICARE: LISA M GITELSON DMD PC

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	261QD0000X	Dental Clinic/Center	D7623	OR

General Provider Information

NPI Number	:	1841283421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA M GITELSON DMD PC

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	:	503-463-4666

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	:	503-463-4666

Authorized Official
Title or Position	:	DOCTOR OWNER
Name	:	DR. LISA M GITELSON
Credential	:	DMD PC
Telephone Number	:	503-463-4663

Provider Enumeration Date	:	08/29/2005
Last Update Date	:	08/06/2008

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