MEDICARE: DR. MARY V MELLARD 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	122300000X	Dentist	13920	TX

General Provider Information

NPI Number	:	1851623995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY V MELLARD DDS

Provider Business Mailing Address
First Line	:	24200 W IH 10
Second Line	:	SUITE 112
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257-1145
Country	:	US
Telephone Number	:	210-687-1133
Fax Number	:	210-687-1132

Provider Business Practice Location Address
First Line	:	24200 W IH 10
Second Line	:	SUITE 112
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257-1145
Country	:	US
Telephone Number	:	210-687-1133
Fax Number	:	210-687-1132

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

Provider Enumeration Date	:	01/29/2010
Last Update Date	:	01/29/2010

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