1306973029 NPI number — DR. MICHAEL SCOTT WASSERMAN DDS

Table of content: DR. MICHAEL SCOTT WASSERMAN DDS (NPI 1306973029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306973029 NPI number — DR. MICHAEL SCOTT WASSERMAN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WASSERMAN
Provider First Name:
MICHAEL
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306973029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1770 1ST ST
Provider Second Line Business Mailing Address:
#360
Provider Business Mailing Address City Name:
HIGHLAND PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60035-3200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-432-1416
Provider Business Mailing Address Fax Number:
847-433-6151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1770 1ST ST
Provider Second Line Business Practice Location Address:
#360
Provider Business Practice Location Address City Name:
HIGHLAND PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60035-3200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-432-1416
Provider Business Practice Location Address Fax Number:
847-433-6151
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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