MEDICARE: SOUTHBRIDGE PLACE DENTAL, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223P0106X	Oral and Maxillofacial Pathology Dentistry
2	1223P0221X	Pediatric Dentistry
3	1223P0300X	Periodontics
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
5	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
6	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1861960270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHBRIDGE PLACE DENTAL, P.C.

Provider Business Mailing Address
First Line	:	1090 NORTHCHASE PKWY SE STE 290
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-6402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	544 SOUTHBRIDGE ST
Second Line	:
City	:	WORCESTER
State	:	MA
Zip	:	01610-1716
Country	:	US
Telephone Number	:	774-243-8592
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DALE MAYFIELD
Credential	:
Telephone Number	:	770-916-5036

Provider Enumeration Date	:	11/05/2018
Last Update Date	:	11/05/2018

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Directions to “SOUTHBRIDGE PLACE DENTAL, P.C. ” Practice Location

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