MEDICARE: G.MICHAEL MAITRE DMD PA

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	4529	AL
2	1223G0001X	General Practice Dentistry	5412	AL
3	1223G0001X	General Practice Dentistry	5689	AL
4	1223G0001X	General Practice Dentistry	2723	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	510-94272	OTHER	AL	BLUE CROSS BLUE SHIELD AL
2	515-32488	OTHER	AL	BLUE CROSS BLUE SHIELD AL
3	510-92383	OTHER	AL	BLUE CROSS BLUE SHILED AL

General Provider Information

NPI Number	:	1306871405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	G.MICHAEL MAITRE DMD PA

Provider Business Mailing Address
First Line	:	801 UNIVERSITY BLVD S # A
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36609-2923
Country	:	US
Telephone Number	:	251-344-4571
Fax Number	:	251-344-2413

Provider Business Practice Location Address
First Line	:	801 UNIVERSITY BLVD S # A
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36609-2923
Country	:	US
Telephone Number	:	251-344-4571
Fax Number	:	251-344-2413

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GEORGE MICHAEL MAITRE
Credential	:	DMD
Telephone Number	:	251-344-4571

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	07/09/2009

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