MEDICARE: SCOTT WAYNE STIFFLE 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	1223G0001X	General Practice Dentistry		IL

General Provider Information

NPI Number	:	1912176967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT WAYNE STIFFLE DDS

Provider Business Mailing Address
First Line	:	2758 N RACINE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1206
Country	:	US
Telephone Number	:	773-348-0565
Fax Number	:

Provider Business Practice Location Address
First Line	:	2758 N RACINE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1206
Country	:	US
Telephone Number	:	773-348-0565
Fax Number	:

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

Provider Enumeration Date	:	02/25/2008
Last Update Date	:	02/25/2008

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Directions to “ SCOTT WAYNE STIFFLE DDS” Practice Location

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