Healthcare Provider Details

I. General information

NPI: 1972211134
Provider Name (Legal Business Name): MARK A. MASTELLOTTO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 11/07/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 RIVERSIDE AVE
ADRIAN MI
49221-1445
US

IV. Provider business mailing address

760 RIVERSIDE AVE
ADRIAN MI
49221-1445
US

V. Phone/Fax

Practice location:
  • Phone: 517-263-0338
  • Fax: 517-263-1138
Mailing address:
  • Phone: 517-263-0338
  • Fax: 517-263-1138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK ARTHUR MASTELLOTTO
Title or Position: OWNER
Credential: DDS
Phone: 517-263-0338