MEDICARE: DR. MARY A SPEICHER DMD

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	0401007331	VA

General Provider Information

NPI Number	:	1205839073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY A SPEICHER DMD

Provider Business Mailing Address
First Line	:	7519 LAKE MANASSAS DRIVE
Second Line	:	SUITE 301
City	:	GAINESVILLE
State	:	VA
Zip	:	20155
Country	:	US
Telephone Number	:	703-743-5937
Fax Number	:

Provider Business Practice Location Address
First Line	:	7915 LAKE MANASSAS DR
Second Line	:	SUITE 115
City	:	GAINESVILLE
State	:	VA
Zip	:	20155-3258
Country	:	US
Telephone Number	:	571-261-9470
Fax Number	:	571-261-9472

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	12/02/2021

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