MEDICARE: MITCHELL C MACTIER 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	1223G0001X	General Practice Dentistry	34201	TX

General Provider Information

NPI Number	:	1497249965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL C MACTIER DDS

Provider Business Mailing Address
First Line	:	600 N SHEPHERD DR STE 164
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-4652
Country	:	US
Telephone Number	:	281-768-8922
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 N SHEPHERD DR STE 164
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-4652
Country	:	US
Telephone Number	:	281-768-8922
Fax Number	:

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

Provider Enumeration Date	:	06/19/2018
Last Update Date	:	09/22/2021

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