Lee Michael Ceresa, D.D.S.
Individual provider Active NPI Endodontics · Peru, IL
NPI 1063513117 · NPPES record last updated Sep 30, 2014
Key facts
- NPI
- 1063513117
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Endodontics 1223E0200X
- License
- 021001935 (IL)
- Practice address
- 1601 4TH St
Peru, IL 61354-3507 - Phone
- (815) 224-3636
- Fax
- (815) 220-1479
- NPI assigned
- Sep 25, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20130703000113 | IL | Order and Referring Only - Oral Surgery |
3577703123 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 021001935 | IL | MD | Endodontist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Illinois Valley Endodontics LLC | Endodontics | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Endodontics | 1223E0200X | 021001935 | IL | Yes |
Addresses
Primary practice location
1601 4TH St
Peru, IL 61354-3507
Mailing address
1601 4TH St
Peru, IL 61354-3507
Phone (815) 224-3636
Other providers in Peru, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 30, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.