MEDICARE: MAHR ELDER DDS MD P C

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D46586	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G93803-01	OTHER	CA	MEDI-CAL

General Provider Information

NPI Number	:	1215128988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAHR ELDER DDS MD P C

Provider Business Mailing Address
First Line	:	1805 NOVATO BLVD
Second Line	:	SUITE 1
City	:	NOVATO
State	:	CA
Zip	:	94947-2934
Country	:	US
Telephone Number	:	415-892-1190
Fax Number	:	415-892-7355

Provider Business Practice Location Address
First Line	:	1805 NOVATO BLVD
Second Line	:	SUITE 1
City	:	NOVATO
State	:	CA
Zip	:	94947-2934
Country	:	US
Telephone Number	:	415-892-1190
Fax Number	:	415-892-7355

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MAHR FAIRUKE ELDER
Credential	:	DDS, MD
Telephone Number	:	415-892-1190

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	08/10/2016

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