MEDICARE: DR. MARCOS CACERES D.M.D.

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	10991	GA

General Provider Information

NPI Number	:	1275557548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCOS CACERES D.M.D.

Provider Business Mailing Address
First Line	:	4485 N TOWN SQ
Second Line	:	SUITE 108
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-2242
Country	:	US
Telephone Number	:
Fax Number	:	770-943-2727

Provider Business Practice Location Address
First Line	:	4485 N TOWN SQ
Second Line	:	SUITE 108
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-2242
Country	:	US
Telephone Number	:	770-943-3344
Fax Number	:	770-943-2727

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

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	07/08/2007

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