MEDICARE: DR. FREDERIC CARL MANDELL 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	D022248	CA

General Provider Information

NPI Number	:	1346454329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDERIC CARL MANDELL DDS

Provider Business Mailing Address
First Line	:	12840 RIVERSIDE DR
Second Line	:	SUITE 508
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-3327
Country	:	US
Telephone Number	:	818-506-2424
Fax Number	:	818-763-5679

Provider Business Practice Location Address
First Line	:	12840 RIVERSIDE DR
Second Line	:	SUITE 508
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-3327
Country	:	US
Telephone Number	:	818-506-2424
Fax Number	:	818-763-5679

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

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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