MEDICARE: DR. MANDY DAITCH D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5465	AZ

General Provider Information

NPI Number	:	1033224829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MANDY DAITCH D.D.S.

Provider Business Mailing Address
First Line	:	6320A W UNION HILLS DR
Second Line	:	SUITE #280
City	:	GLENDALE
State	:	AZ
Zip	:	85308-7177
Country	:	US
Telephone Number	:	623-362-1150
Fax Number	:	623-362-1353

Provider Business Practice Location Address
First Line	:	6320A W UNION HILLS DR
Second Line	:	SUITE #280
City	:	GLENDALE
State	:	AZ
Zip	:	85308-7177
Country	:	US
Telephone Number	:	623-362-1150
Fax Number	:	623-362-1353

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/08/2007

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