MEDICARE: DR. DONALD EDWARD ISSELHARD 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	10765	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200666093	OTHER	MO	CORPRATION TAX ID
2	793073	OTHER	PA	UNITED CONCORDIA

General Provider Information

NPI Number	:	1952412991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD EDWARD ISSELHARD DDS

Provider Business Mailing Address
First Line	:	12401 OLIVE BLVD
Second Line	:	SUITE 200
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-5448
Country	:	US
Telephone Number	:	314-275-9009
Fax Number	:	314-275-9010

Provider Business Practice Location Address
First Line	:	12401 OLIVE BLVD
Second Line	:	SUITE 200
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-5448
Country	:	US
Telephone Number	:	314-275-9009
Fax Number	:	314-275-9010

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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