MEDICARE: MIDWEST ORAL HEALTH, 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	1223G0001X	General Practice Dentistry	6961-15	WI

General Provider Information

NPI Number	:	1538602503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST ORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	151 E FOREST AVE
Second Line	:
City	:	NEENAH
State	:	WI
Zip	:	54956-2758
Country	:	US
Telephone Number	:	920-725-4307
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 E FOREST AVE
Second Line	:
City	:	NEENAH
State	:	WI
Zip	:	54956-2758
Country	:	US
Telephone Number	:	920-725-4307
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. BRYAN JAMES MICK
Credential	:	DDS
Telephone Number	:	920-725-4307

Provider Enumeration Date	:	11/23/2016
Last Update Date	:	11/23/2016

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