MEDICARE: DR. GISELE MAINVILLE D.M.D.

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	RES.2972	OH

General Provider Information

NPI Number	:	1912200239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GISELE MAINVILLE D.M.D.

Provider Business Mailing Address
First Line	:	425 N FRONT ST
Second Line	:	APT 623
City	:	COLUMBUS
State	:	OH
Zip	:	43215-2274
Country	:	US
Telephone Number	:	614-653-9782
Fax Number	:

Provider Business Practice Location Address
First Line	:	305 W 12TH AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43210-1267
Country	:	US
Telephone Number	:	614-292-6577
Fax Number	:

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

Provider Enumeration Date	:	12/08/2010
Last Update Date	:	12/08/2010

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