MEDICARE: MRS. KATHI MARIE MANSELL-GLOWACKY

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	3701	AZ

General Provider Information

NPI Number	:	1609874361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHI MARIE MANSELL-GLOWACKY

Provider Business Mailing Address
First Line	:	9370 E. CALLE DE LAS BRISAS
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85255-4335
Country	:	US
Telephone Number	:	480-502-1843
Fax Number	:

Provider Business Practice Location Address
First Line	:	7595 E. MCDONALD DRIVE
Second Line	:	SUITE 110
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85250-6004
Country	:	US
Telephone Number	:	480-948-1255
Fax Number	:	480-951-5844

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

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

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