MEDICARE: DR. RAYMOND J MANSFIELD D.D.S.

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	6165	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	075154	OTHER	MD	TRICARE

General Provider Information

NPI Number	:	1386647758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAYMOND J MANSFIELD D.D.S.

Provider Business Mailing Address
First Line	:	13239 EXECUTIVE PARK TER
Second Line	:
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-2648
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13239 EXECUTIVE PARK TER
Second Line	:
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-2648
Country	:	US
Telephone Number	:	301-540-5195
Fax Number	:

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	07/08/2007

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