MEDICARE: MICHAEL A MANDINO JR D.D.S DR LOUIS A JULIANO D.D.S. LLC

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	4750	CT
2	122300000X	Dentist	10118	CT
3	1223G0001X	General Practice Dentistry
4	122300000X	Dentist	4393	CT

General Provider Information

NPI Number	:	1356642540
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL A MANDINO JR D.D.S DR LOUIS A JULIANO D.D.S. LLC

Provider Business Mailing Address
First Line	:	276 HIGHLAND AVE
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06708-3022
Country	:	US
Telephone Number	:	203-575-9798
Fax Number	:	203-575-1286

Provider Business Practice Location Address
First Line	:	276 HIGHLAND AVE
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06708-3022
Country	:	US
Telephone Number	:	203-575-9798
Fax Number	:	203-575-1286

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL A MANDINO JR.
Credential	:	D.D.S
Telephone Number	:	203-575-9798

Provider Enumeration Date	:	11/04/2010
Last Update Date	:	11/10/2014

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