MEDICARE: MARK ROGER VERMILLION 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	1223G0001X	General Practice Dentistry	18554	OH

General Provider Information

NPI Number	:	1730246869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ROGER VERMILLION D.D.S.

Provider Business Mailing Address
First Line	:	5925 N MAIN ST
Second Line	:	SUITE B
City	:	DAYTON
State	:	OH
Zip	:	45415-3153
Country	:	US
Telephone Number	:	937-275-2211
Fax Number	:	937-275-4408

Provider Business Practice Location Address
First Line	:	5925 N MAIN ST
Second Line	:	SUITE B
City	:	DAYTON
State	:	OH
Zip	:	45415-3153
Country	:	US
Telephone Number	:	937-275-2211
Fax Number	:	937-275-4408

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

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

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