MEDICARE: DR. MANDIE DRIVER 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	122300000X	Dentist	7182	LA

General Provider Information

NPI Number	:	1326613423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MANDIE DRIVER DDS

Provider Business Mailing Address
First Line	:	37279 MARKET PLACE DR
Second Line	:
City	:	PRAIRIEVILLE
State	:	LA
Zip	:	70769-3487
Country	:	US
Telephone Number	:	225-673-1647
Fax Number	:

Provider Business Practice Location Address
First Line	:	37279 MARKET PLACE DR
Second Line	:
City	:	PRAIRIEVILLE
State	:	LA
Zip	:	70769-3487
Country	:	US
Telephone Number	:	225-673-1647
Fax Number	:

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

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	05/21/2021

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