Provider Demographics
NPI:1306973029
Name:WASSERMAN, MICHAEL SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:WASSERMAN
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 1:1770 1ST ST
Mailing Address - Street 2:#360
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3200
Mailing Address - Country:US
Mailing Address - Phone:847-432-1416
Mailing Address - Fax:847-433-6151
Practice Address - Street 1:1770 1ST ST
Practice Address - Street 2:#360
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3200
Practice Address - Country:US
Practice Address - Phone:847-432-1416
Practice Address - Fax:847-433-6151
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice