MEDICARE: JOHN PHILLIP MASEL 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	5001685	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5001685	OTHER	WI	DENTAL LICENSE

General Provider Information

NPI Number	:	1639280811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN PHILLIP MASEL D.D.S.

Provider Business Mailing Address
First Line	:	2130 W BOLIVAR AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53221-2214
Country	:	US
Telephone Number	:	414-282-9783
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 W OKLAHOMA AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-4623
Country	:	US
Telephone Number	:	414-671-4848
Fax Number	:

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

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

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