MEDICARE: MOBILE DENTISTS MANAGEMENT II, LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689781270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE DENTISTS MANAGEMENT II, LLC

Provider Business Mailing Address
First Line	:	PO BOX 250310
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48325-0310
Country	:	US
Telephone Number	:	888-833-8441
Fax Number	:	888-330-4331

Provider Business Practice Location Address
First Line	:	133 W MARKET ST
Second Line	:	SUITE 270
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-2801
Country	:	US
Telephone Number	:	888-833-8441
Fax Number	:	888-330-4331

Authorized Official
Title or Position	:	DENTAL DIRECTOR
Name	:	DR. MARGO YELLIN WOLL
Credential	:	DDS
Telephone Number	:	888-833-8441

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	06/18/2008

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