MEDICARE: MAHTOMEDI DENTAL CLINIC

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	11396	MN
2	1223G0001X	General Practice Dentistry	D8217	MN

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	:	1841462652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAHTOMEDI DENTAL CLINIC

Provider Business Mailing Address
First Line	:	814 MAHTOMEDI AVE
Second Line	:
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-1730
Country	:	US
Telephone Number	:	651-426-0011
Fax Number	:	651-426-2075

Provider Business Practice Location Address
First Line	:	814 MAHTOMEDI AVE
Second Line	:	MAHTOMEDI DENTAL
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-1730
Country	:	US
Telephone Number	:	651-426-0011
Fax Number	:	651-426-2075

Authorized Official
Title or Position	:	OWNER - DENTIST
Name	:	DR. TIMOTHY A BRAY
Credential	:	DDS MPH
Telephone Number	:	651-426-0011

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	07/18/2008

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