MEDICARE: MAURER FAMILY DENTAL LLC

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

General Provider Information

NPI Number	:	1952829889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAURER FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	1526 S BATES AVE
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-3348
Country	:	US
Telephone Number	:	217-314-9317
Fax Number	:

Provider Business Practice Location Address
First Line	:	4526 OLD SALEM LN
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-6006
Country	:	US
Telephone Number	:	217-546-8600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TRISHA FLUCKIGER
Credential	:	DMD
Telephone Number	:	217-546-8600

Provider Enumeration Date	:	08/30/2017
Last Update Date	:	08/30/2017

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