MEDICARE: MUNDO MANAGEMENT GROUP, 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	122300000X	Dentist	8552	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922480060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MUNDO MANAGEMENT GROUP, LLC

Provider Business Mailing Address
First Line	:	3463 HIGHWAY 21 BYP STE 1
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29715-7245
Country	:	US
Telephone Number	:	704-825-2081
Fax Number	:	803-335-5189

Provider Business Practice Location Address
First Line	:	3463 HIGHWAY 21 BYP STE 1
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29715-7245
Country	:	US
Telephone Number	:	704-825-2081
Fax Number	:	803-335-5189

Authorized Official
Title or Position	:	DR. BLAKE KINGSBURY, D.M.D
Name	:	DR. BLAKE CARSON KINGSBURY
Credential	:	DMD
Telephone Number	:	704-825-2081

Provider Enumeration Date	:	06/25/2015
Last Update Date	:	06/25/2015

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