MEDICARE: DR. MICHAEL LANDERS MAULDIN 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	122300000X	Dentist	9804	TX

General Provider Information

NPI Number	:	1588670939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL LANDERS MAULDIN D.D.S.

Provider Business Mailing Address
First Line	:	501 MOORE AVE
Second Line	:
City	:	PORTLAND
State	:	TX
Zip	:	78374-1605
Country	:	US
Telephone Number	:	361-643-7811
Fax Number	:	361-643-4028

Provider Business Practice Location Address
First Line	:	501 MOORE AVE
Second Line	:
City	:	PORTLAND
State	:	TX
Zip	:	78374-1605
Country	:	US
Telephone Number	:	361-643-7811
Fax Number	:	361-643-4028

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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