Provider Demographics
NPI:1952485096
Name:REISBERG, DAVID JOEL (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOEL
Last Name:REISBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 S. PAULINA ST.
Mailing Address - Street 2:MC 588
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4305
Mailing Address - Country:US
Mailing Address - Phone:312-996-6933
Mailing Address - Fax:312-355-4173
Practice Address - Street 1:811 S. PAULINA ST.
Practice Address - Street 2:MC 588
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4305
Practice Address - Country:US
Practice Address - Phone:312-996-6933
Practice Address - Fax:312-355-4173
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190173831223P0700X
IL019-017383204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
T36981Medicare UPIN