MEDICARE: THOMAS M. PEDAVOLI DDS 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	122300000X	Dentist	12008862A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215477088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS M. PEDAVOLI DDS INC.

Provider Business Mailing Address
First Line	:	PO BOX 1049
Second Line	:
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-5049
Country	:	US
Telephone Number	:	574-936-2527
Fax Number	:	574-936-5363

Provider Business Practice Location Address
First Line	:	850 COLUMBUS DR
Second Line	:
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-1877
Country	:	US
Telephone Number	:	574-936-2527
Fax Number	:	574-936-5363

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. THOMAS MICHAEL PEDAVOLI
Credential	:	DDS
Telephone Number	:	574-936-2527

Provider Enumeration Date	:	02/27/2017
Last Update Date	:	02/27/2017

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