MEDICARE: MCDONOUGH DENTAL CORPORATION

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1386285427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCDONOUGH DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:	714-845-8500
Fax Number	:	303-952-0892

Provider Business Practice Location Address
First Line	:	12013 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1201
Country	:	US
Telephone Number	:	310-219-6039
Fax Number	:	310-219-6038

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHAELAN D MCDONOUGH
Credential	:	DDS
Telephone Number	:	310-219-6039

Provider Enumeration Date	:	09/30/2019
Last Update Date	:	03/08/2022

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Directions to “MCDONOUGH DENTAL CORPORATION ” Practice Location

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