MEDICARE: LMG, INC

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	1223P0106X	Oral and Maxillofacial Pathology Dentistry		WI

General Provider Information

NPI Number	:	1134235427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LMG, INC

Provider Business Mailing Address
First Line	:	2626 N 76TH STREET
Second Line	:	SUITE 101
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-1137
Country	:	US
Telephone Number	:	414-476-9400
Fax Number	:	414-755-4769

Provider Business Practice Location Address
First Line	:	2626 N 76TH STREET
Second Line	:	SUITE 101
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-1137
Country	:	US
Telephone Number	:	414-476-9400
Fax Number	:	414-755-4769

Authorized Official
Title or Position	:	OWNER-PRESIDENT
Name	:	JAY L MACKMAN
Credential	:	D.D.S.
Telephone Number	:	414-476-9400

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	01/19/2017

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