MEDICARE: DR. THADDEUS JUDE JOHN MANDATO D.D.S.

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	30-01-5181	OH

General Provider Information

NPI Number	:	1508961533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THADDEUS JUDE JOHN MANDATO D.D.S.

Provider Business Mailing Address
First Line	:	21245 LORAIN RD
Second Line	:	SUITE 100
City	:	FAIRVIEW PARK
State	:	OH
Zip	:	44126-2146
Country	:	US
Telephone Number	:	440-331-0164
Fax Number	:	440-331-0165

Provider Business Practice Location Address
First Line	:	21245 LORAIN RD
Second Line	:	SUITE 100
City	:	FAIRVIEW PARK
State	:	OH
Zip	:	44126-2146
Country	:	US
Telephone Number	:	440-331-0164
Fax Number	:	440-331-0165

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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