MEDICARE: DR. MENA GHALY 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	6894-15	WI

General Provider Information

NPI Number	:	1477819068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MENA GHALY D.D.S

Provider Business Mailing Address
First Line	:	2509 EMSLIE DR
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53188-2048
Country	:	US
Telephone Number	:	262-442-8297
Fax Number	:

Provider Business Practice Location Address
First Line	:	11345 N PORT WASHINGTON RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-3411
Country	:	US
Telephone Number	:	262-442-8297
Fax Number	:

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

Provider Enumeration Date	:	04/08/2012
Last Update Date	:	05/25/2012

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