MEDICARE: MARK G. PELLETIER, DDS, PA

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	3232	SC

General Provider Information

NPI Number	:	1174797526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK G. PELLETIER, DDS, PA

Provider Business Mailing Address
First Line	:	PO BOX 1181
Second Line	:
City	:	IRMO
State	:	SC
Zip	:	29063-1181
Country	:	US
Telephone Number	:	803-781-7901
Fax Number	:	803-749-1376

Provider Business Practice Location Address
First Line	:	900 LAKE MURRAY BLVD
Second Line	:
City	:	IRMO
State	:	SC
Zip	:	29063-2923
Country	:	US
Telephone Number	:	803-781-7901
Fax Number	:	803-749-1376

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	DR. MARK G. PELLETIER
Credential	:	D.D.S.
Telephone Number	:	803-781-7901

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	04/16/2008

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