MEDICARE: PAYNESVILLE FAMILY DENTAL

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	12437	MN
2	122300000X	Dentist	12231	MN

General Provider Information

NPI Number	:	1881013019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAYNESVILLE FAMILY DENTAL

Provider Business Mailing Address
First Line	:	204 W JAMES ST
Second Line	:
City	:	PAYNESVILLE
State	:	MN
Zip	:	56362-1219
Country	:	US
Telephone Number	:	320-243-7209
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 W JAMES ST
Second Line	:
City	:	PAYNESVILLE
State	:	MN
Zip	:	56362-1219
Country	:	US
Telephone Number	:	320-243-7209
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. CHRIS MCGREW
Credential	:
Telephone Number	:	320-243-7209

Provider Enumeration Date	:	04/15/2014
Last Update Date	:	04/15/2014

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