MEDICARE: EAST 22ND STREET DENTAL, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1396832994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST 22ND STREET DENTAL, P.C.

Provider Business Mailing Address
First Line	:	210 INTERSTATE NORTH PKWY SE STE 300
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-2233
Country	:	US
Telephone Number	:	770-916-5028
Fax Number	:	678-247-7858

Provider Business Practice Location Address
First Line	:	2990 S 6TH AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85713
Country	:	US
Telephone Number	:	520-325-5665
Fax Number	:	520-327-5666

Authorized Official
Title or Position	:	OWNER
Name	:	DALE GARY MAYFIELD
Credential	:
Telephone Number	:	770-916-5036

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	04/24/2026

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