MEDICARE: MOUNTAIN VIEW ORAL SURGERY & DENTAL IMPLANTS LLC

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DN014013	GA

General Provider Information

NPI Number	:	1104172741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN VIEW ORAL SURGERY & DENTAL IMPLANTS LLC

Provider Business Mailing Address
First Line	:	121 MARBLE MILL RD NW
Second Line	:	SUITE 202
City	:	MARIETTA
State	:	GA
Zip	:	30060-7959
Country	:	US
Telephone Number	:	770-218-9135
Fax Number	:	866-224-2735

Provider Business Practice Location Address
First Line	:	121 MARBLE MILL RD NW
Second Line	:	SUITE 202
City	:	MARIETTA
State	:	GA
Zip	:	30060-7959
Country	:	US
Telephone Number	:	770-218-9135
Fax Number	:	866-224-2735

Authorized Official
Title or Position	:	ORAL SURGEON
Name	:	MARK A CHISHOM
Credential	:	DMD
Telephone Number	:	770-218-9135

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	08/01/2012

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