MEDICARE: DR. JAY L MACKMAN 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	1223P0106X	Oral and Maxillofacial Pathology Dentistry	2793-015	WI

General Provider Information

NPI Number	:	1821194184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAY L MACKMAN DDS

Provider Business Mailing Address
First Line	:	2626 N 76TH ST
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213
Country	:	US
Telephone Number	:	414-476-9400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2626 N 76TH ST
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213
Country	:	US
Telephone Number	:	414-476-9400
Fax Number	:

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

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/08/2007

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