MEDICARE: MRS. MICAELLA QUEIROZ BORGES-SCHOCKER D.M.D.

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	1223P0221X	Pediatric Dentistry	030252	PA

General Provider Information

NPI Number	:	1912126509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICAELLA QUEIROZ BORGES-SCHOCKER D.M.D.

Provider Business Mailing Address
First Line	:	6 HOWE CT
Second Line	:
City	:	GLEN MILLS
State	:	PA
Zip	:	19342-1783
Country	:	US
Telephone Number	:	610-399-0821
Fax Number	:

Provider Business Practice Location Address
First Line	:	780 W LANCASTER AVE
Second Line	:	SUITE 100
City	:	BRYN MAWR
State	:	PA
Zip	:	19010-3415
Country	:	US
Telephone Number	:	610-527-2434
Fax Number	:

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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