MEDICARE: NORTH MESA DENTAL, PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223P0221X	Pediatric Dentistry
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
4	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1619148723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH MESA DENTAL, PC

Provider Business Mailing Address
First Line	:	1090 NORTHCHASE PKWY SE
Second Line	:	SUITE 150
City	:	MARIETTA
State	:	GA
Zip	:	30067-6405
Country	:	US
Telephone Number	:	770-916-5028
Fax Number	:	678-247-7858

Provider Business Practice Location Address
First Line	:	3711 GREGORY ST
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-1614
Country	:	US
Telephone Number	:	800-920-9947
Fax Number	:	678-904-5666

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DALE G MAYFIELD
Credential	:	DMD
Telephone Number	:	770-916-5036

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	06/17/2019

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