MEDICARE: DR. MARK DAVID LIVELY 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN11635	FL

General Provider Information

NPI Number	:	1346431301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK DAVID LIVELY D.M.D.

Provider Business Mailing Address
First Line	:	106 COLORADO AVE
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-2106
Country	:	US
Telephone Number	:	772-287-3999
Fax Number	:	772-287-1719

Provider Business Practice Location Address
First Line	:	106 COLORADO AVE
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-2106
Country	:	US
Telephone Number	:	772-287-3999
Fax Number	:	772-287-1719

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

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	08/06/2007

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