MEDICARE: DR. MARISA C BLICKHAN DMD

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	019.035173	IL

General Provider Information

NPI Number	:	1952143968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARISA C BLICKHAN DMD

Provider Business Mailing Address
First Line	:	1610 SHURTLEFF CT
Second Line	:
City	:	ALTON
State	:	IL
Zip	:	62002-4067
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1427 LEWIS RD
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-4148
Country	:	US
Telephone Number	:	618-207-4871
Fax Number	:

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

Provider Enumeration Date	:	06/10/2024
Last Update Date	:	06/10/2024

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