MEDICARE: DR. JACK TODD MAYHEW DMD

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	8930	CO

General Provider Information

NPI Number	:	1306915376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK TODD MAYHEW DMD

Provider Business Mailing Address
First Line	:	2620 TENDERFOOT HILL STREET
Second Line	:	SUITE 100
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8353
Country	:	US
Telephone Number	:	719-540-5540
Fax Number	:	719-540-5541

Provider Business Practice Location Address
First Line	:	2620 TENDERFOOT HILL STREET
Second Line	:	SUITE 100
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8353
Country	:	US
Telephone Number	:	719-540-5540
Fax Number	:	719-540-5541

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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