MEDICARE: DR. MITCHELL INGRAM HENN 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	1223G0001X	General Practice Dentistry	14593	OH

General Provider Information

NPI Number	:	1811999170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITCHELL INGRAM HENN DDS

Provider Business Mailing Address
First Line	:	24 LEXINGTON BLVD
Second Line	:
City	:	MADISON
State	:	OH
Zip	:	44057-3150
Country	:	US
Telephone Number	:	440-428-1118
Fax Number	:	440-428-9607

Provider Business Practice Location Address
First Line	:	24 LEXINGTON BLVD
Second Line	:
City	:	MADISON
State	:	OH
Zip	:	44057-3150
Country	:	US
Telephone Number	:	440-428-1118
Fax Number	:	440-428-9607

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/08/2007

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