=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750532818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE M MAYER D.M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2008
-----------------------------------------------------
Last Update Date | 10/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 CONNECTICUT RD
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33936-6117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-369-5861
-----------------------------------------------------
Fax | 239-369-7121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 881 USS JAMES MADISON RD NBHC DENTAL DEPARTMENT
-----------------------------------------------------
City | KINGS BAY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-573-4212
-----------------------------------------------------
Fax | 912-573-2085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN18329
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------