Healthcare Provider Details

I. General information

NPI: 1790979664
Provider Name (Legal Business Name): MARK D. MEDAUGH, D.M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GEORGE HANNUM RD
BELCHERTOWN MA
01007-8915
US

IV. Provider business mailing address

20 GEORGE HANNUM RD PO BOX 1310
BELCHERTOWN MA
01007-8915
US

V. Phone/Fax

Practice location:
  • Phone: 413-323-4335
  • Fax: 413-323-7253
Mailing address:
  • Phone: 413-323-4335
  • Fax: 413-323-7253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARK DAVID MEDAUGH
Title or Position: PRESIDENT
Credential: D.M.D
Phone: 413-323-4335