MEDICARE: DR. MARK STEVEN MANDEL D.D.S.

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	5000797	WI

General Provider Information

NPI Number	:	1225103104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK STEVEN MANDEL D.D.S.

Provider Business Mailing Address
First Line	:	5960 W BROWN DEER RD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-2310
Country	:	US
Telephone Number	:	414-355-3551
Fax Number	:	414-355-4554

Provider Business Practice Location Address
First Line	:	5960 W BROWN DEER RD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-2310
Country	:	US
Telephone Number	:	414-355-3551
Fax Number	:	414-355-4554

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

Provider Enumeration Date	:	11/23/2006
Last Update Date	:	07/08/2007

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