MEDICARE: DR. MARK WARD BAIN 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	029474	NY

General Provider Information

NPI Number	:	1104921485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WARD BAIN D.D.S.

Provider Business Mailing Address
First Line	:	26 COLUMBIA AVE
Second Line	:
City	:	DEPEW
State	:	NY
Zip	:	14043-2309
Country	:	US
Telephone Number	:	716-685-4020
Fax Number	:	716-685-4021

Provider Business Practice Location Address
First Line	:	26 COLUMBIA AVE
Second Line	:
City	:	DEPEW
State	:	NY
Zip	:	14043-2309
Country	:	US
Telephone Number	:	716-685-4020
Fax Number	:	716-685-4021

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

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	07/08/2007

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