MEDICARE: DR. GARY R DETTMAN 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	122300000X	Dentist	019-020199	IL

General Provider Information

NPI Number	:	1851470470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY R DETTMAN DDS

Provider Business Mailing Address
First Line	:	110 E WASHINGTON ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-3107
Country	:	US
Telephone Number	:	815-568-1202
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 E WASHINGTON ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-3107
Country	:	US
Telephone Number	:	815-568-1202
Fax Number	:

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	09/09/2008

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