MEDICARE: MARK SHURETT DDS PC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1679551790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK SHURETT DDS PC

Provider Business Mailing Address
First Line	:	1806 OVER LAKE DR SE
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30013-1745
Country	:	US
Telephone Number	:	770-760-7900
Fax Number	:	770-760-1375

Provider Business Practice Location Address
First Line	:	1806 OVER LAKE DR SE
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30013-1745
Country	:	US
Telephone Number	:	770-760-7900
Fax Number	:	770-760-1375

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. JOSEPH P RHODES
Credential	:
Telephone Number	:	770-760-7900

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	04/10/2008

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