MEDICARE: DR. MARK DINNER D.M.D.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DS019991L	PA

General Provider Information

NPI Number	:	1326044116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK DINNER D.M.D.

Provider Business Mailing Address
First Line	:	1201 N CHURCH ST
Second Line	:	STE 209
City	:	HAZLETON
State	:	PA
Zip	:	18202-1455
Country	:	US
Telephone Number	:	570-459-6245
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 N CHURCH ST
Second Line	:	STE 209
City	:	HAZLETON
State	:	PA
Zip	:	18202-1455
Country	:	US
Telephone Number	:	570-459-6245
Fax Number	:

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

Provider Enumeration Date	:	06/26/2005
Last Update Date	:	07/08/2007

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