MEDICARE: DR. MARK MINA GOERGY DMD

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	122300000X	Dentist	30.025815	OH

General Provider Information

NPI Number	:	1053978221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK MINA GOERGY DMD

Provider Business Mailing Address
First Line	:	2460 FAIRMOUNT BLVD STE 218
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44106-3125
Country	:	US
Telephone Number	:	216-791-5191
Fax Number	:

Provider Business Practice Location Address
First Line	:	2460 FAIRMOUNT BLVD STE 218
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44106-3125
Country	:	US
Telephone Number	:	216-791-5191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2019
Last Update Date	:	12/12/2019

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