Healthcare Provider Details

I. General information

NPI: 1780851386
Provider Name (Legal Business Name): GARY WAYNE MENDESE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 CENTRAL AVE
DOVER NH
03820
US

IV. Provider business mailing address

784 CENTRAL AVE
DOVER NH
03820-2549
US

V. Phone/Fax

Practice location:
  • Phone: 603-742-5556
  • Fax:
Mailing address:
  • Phone: 603-742-5556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number240786
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number240786
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number240786
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: