MEDICARE: DR. MARK E STOTZ DDS

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	M672	SD

General Provider Information

NPI Number	:	1679625784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK E STOTZ DDS

Provider Business Mailing Address
First Line	:	4273 ROSEMARY LN
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-6903
Country	:	US
Telephone Number	:	605-343-2548
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 W MAIN ST STE 304
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2487
Country	:	US
Telephone Number	:	605-342-1432
Fax Number	:	605-342-8131

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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