MEDICARE: MARK D. GEORGE 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	9700	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9700	OTHER	CO	COLORADO DENTAL LICENSE
2	6760	OTHER	NE	NE DENTAL LICENSE

General Provider Information

NPI Number	:	1659527950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK D. GEORGE D.D.S.

Provider Business Mailing Address
First Line	:	7770 N UNION BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-4087
Country	:	US
Telephone Number	:	719-594-9797
Fax Number	:	719-594-6713

Provider Business Practice Location Address
First Line	:	7770 N UNION BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-4087
Country	:	US
Telephone Number	:	719-594-9797
Fax Number	:	719-594-6713

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

Provider Enumeration Date	:	08/18/2008
Last Update Date	:	11/30/2011

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