MEDICARE: DR. MARK EDWARD IOCCA DDS

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	10683	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1953813340	OTHER	MI	MEDICAL PROVIDER

General Provider Information

NPI Number	:	1326028127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK EDWARD IOCCA DDS

Provider Business Mailing Address
First Line	:	2000 SPRING ARBOR RD
Second Line	:	STE A
City	:	JACKSON
State	:	MI
Zip	:	49203-2636
Country	:	US
Telephone Number	:	517-787-5210
Fax Number	:	517-787-9223

Provider Business Practice Location Address
First Line	:	2000 SPRING ARBOR RD
Second Line	:	STE A
City	:	JACKSON
State	:	MI
Zip	:	49203-2636
Country	:	US
Telephone Number	:	517-787-5210
Fax Number	:	517-787-9223

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

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	07/08/2007

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