MEDICARE: MCDONALD-WIN-E-MAC DENTAL

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	D12117	MN

General Provider Information

NPI Number	:	1235317678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCDONALD-WIN-E-MAC DENTAL

Provider Business Mailing Address
First Line	:	105 2ND ST SW
Second Line	:	PO BOX 265
City	:	MCINTOSH
State	:	MN
Zip	:	56556
Country	:	US
Telephone Number	:	218-563-3001
Fax Number	:	218-563-3002

Provider Business Practice Location Address
First Line	:	105 2ND ST SW
Second Line	:
City	:	MCINTOSH
State	:	MN
Zip	:	56556
Country	:	US
Telephone Number	:	218-563-3001
Fax Number	:	218-563-3002

Authorized Official
Title or Position	:	OWNER/PARTNER
Name	:	DR. PETER JAMES MCDONALD
Credential	:	DDS
Telephone Number	:	218-563-3001

Provider Enumeration Date	:	02/07/2008
Last Update Date	:	02/07/2008

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