MEDICARE: NORTH MESA DENTAL, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
2	1223E0200X	Endodontics
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1659548774
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH MESA DENTAL, PC

Provider Business Mailing Address
First Line	:	1090 NORTHCHASE PKWY SE STE 150
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-6407
Country	:	US
Telephone Number	:	770-916-5028
Fax Number	:	678-247-7858

Provider Business Practice Location Address
First Line	:	5130 FAIRBANKS DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79924-3813
Country	:	US
Telephone Number	:	800-920-9947
Fax Number	:	678-904-5666

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DALE G MAYFIELD
Credential	:	DMD
Telephone Number	:	770-916-5036

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	06/17/2019

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