MEDICARE: MDC NORTH FONDY SC

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

General Provider Information

NPI Number	:	1225470842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MDC NORTH FONDY SC

Provider Business Mailing Address
First Line	:	101 CAMELOT DR
Second Line	:	SUITE 3
City	:	FOND DU LAC
State	:	WI
Zip	:	54935-8048
Country	:	US
Telephone Number	:	920-948-6407
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 PROSPECT AVE
Second Line	:
City	:	NORTH FOND DU LAC
State	:	WI
Zip	:	54937-1365
Country	:	US
Telephone Number	:	920-923-0310
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM MAUTHE III
Credential	:
Telephone Number	:	920-948-6407

Provider Enumeration Date	:	07/24/2013
Last Update Date	:	07/24/2013

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