Healthcare Provider Details

I. General information

NPI: 1861483224
Provider Name (Legal Business Name): MACE JACK LANDAU DDS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8720 E MARKET ST #8
WARREN OH
44484-2364
US

IV. Provider business mailing address

140 QUAIL HOLLOW CIR SE
WARREN OH
44484-2323
US

V. Phone/Fax

Practice location:
  • Phone: 330-856-9199
  • Fax: 330-856-3307
Mailing address:
  • Phone: 330-856-3443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30011847
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: