MEDICARE: MARIA EJSBRENNER 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	01921593	IL

General Provider Information

NPI Number	:	1891964524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA EJSBRENNER DDS

Provider Business Mailing Address
First Line	:	5505 N MENARD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1221
Country	:	US
Telephone Number	:	773-631-7070
Fax Number	:	773-631-3770

Provider Business Practice Location Address
First Line	:	5505 N MENARD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1221
Country	:	US
Telephone Number	:	773-631-7070
Fax Number	:	773-631-3770

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

Provider Enumeration Date	:	02/27/2008
Last Update Date	:	02/27/2008

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