MEDICARE: MORTIERE AND GASPAROTTO DDS PC

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	014843	MI

General Provider Information

NPI Number	:	1194813535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORTIERE AND GASPAROTTO DDS PC

Provider Business Mailing Address
First Line	:	5958 N CANTON CENTER RD STE 600
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-2766
Country	:	US
Telephone Number	:	734-459-1950
Fax Number	:	734-459-5710

Provider Business Practice Location Address
First Line	:	5958 N CANTON CENTER RD STE 600
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-2766
Country	:	US
Telephone Number	:	734-459-1950
Fax Number	:	734-459-5710

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. ROBERT CALLISTO GASPAROTTO
Credential	:	DDS
Telephone Number	:	734-459-1950

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2019

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