MEDICARE: MR. DAVID LEE DIBBLE DDS

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	122300000X	Dentist	290-1013248	MI

General Provider Information

NPI Number	:	1184720856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID LEE DIBBLE DDS

Provider Business Mailing Address
First Line	:	18048 HILLTOP DR
Second Line	:
City	:	CHARLEVOIX
State	:	MI
Zip	:	49720-9783
Country	:	US
Telephone Number	:	231-547-5646
Fax Number	:

Provider Business Practice Location Address
First Line	:	2550 N MAIN ST
Second Line	:
City	:	CENTRAL LAKE
State	:	MI
Zip	:	49622
Country	:	US
Telephone Number	:	231-544-8115
Fax Number	:

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	07/08/2007

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