MEDICARE: DAVID JOEL REISBERG 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	1223P0700X	Prosthodontics	019017383	IL
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	019-017383	IL

General Provider Information

NPI Number	:	1952485096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID JOEL REISBERG DDS

Provider Business Mailing Address
First Line	:	811 S. PAULINA ST.
Second Line	:	MC 588
City	:	CHICAGO
State	:	IL
Zip	:	60612-4305
Country	:	US
Telephone Number	:	312-996-6933
Fax Number	:	312-355-4173

Provider Business Practice Location Address
First Line	:	811 S. PAULINA ST.
Second Line	:	MC 588
City	:	CHICAGO
State	:	IL
Zip	:	60612-4305
Country	:	US
Telephone Number	:	312-996-6933
Fax Number	:	312-355-4173

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	12/09/2019

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