MEDICARE: MARJORIE MCDONALD

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	41875	NY

General Provider Information

NPI Number	:	1508124033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARJORIE MCDONALD

Provider Business Mailing Address
First Line	:	1908 FLATBUSH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210
Country	:	US
Telephone Number	:	718-338-8900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1908 FLATBUSH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-4801
Country	:	US
Telephone Number	:	718-338-8900
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	MS. MARJORIE MCDONALD
Credential	:	DDS
Telephone Number	:	718-338-8900

Provider Enumeration Date	:	05/03/2012
Last Update Date	:	10/10/2012

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