=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700053634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARRY A. MENTZEL, D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2008
-----------------------------------------------------
Last Update Date | 05/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19925 E 10 MILE RD
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48080-1069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-772-1880
-----------------------------------------------------
Fax | 586-772-5837
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19925 E 10 MILE RD
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48080-1069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-772-1880
-----------------------------------------------------
Fax | 586-772-5837
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BARRY ALLEN MENTZEL
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 586-772-1880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | M10005
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------