MEDICARE: TRAVERSE DENTAL ASSOCIATES, PLLC

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	12127	MI
2	1223G0001X	General Practice Dentistry	12516	MI
3	1223G0001X	General Practice Dentistry	13833	MI
4	332B00000X	Durable Medical Equipment & Medical Supplies
5	1223G0001X	General Practice Dentistry	2901019122	MI

General Provider Information

NPI Number	:	1336171800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAVERSE DENTAL ASSOCIATES, PLLC

Provider Business Mailing Address
First Line	:	555 SOUTH GARFIELD AVE
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-3423
Country	:	US
Telephone Number	:	231-947-0210
Fax Number	:	231-947-6770

Provider Business Practice Location Address
First Line	:	555 SOUTH GARFIELD AVE
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-3423
Country	:	US
Telephone Number	:	231-947-0210
Fax Number	:	231-947-6770

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTOPHER D MAZZOLA
Credential	:
Telephone Number	:	734-657-1854

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	03/23/2022

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