MEDICARE: DR. MACARIO MELVIN GENTILE III 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	1223G0001X	General Practice Dentistry	1991	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0762858	OTHER	PA	UNITED CONCORDIA
2	0127770	OTHER	AZ	BLUE/BLUE SHIELD
3	1991	OTHER	AZ	DELTA DENTAL

General Provider Information

NPI Number	:	1912900705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MACARIO MELVIN GENTILE III DDS

Provider Business Mailing Address
First Line	:	2135 E UNIVERSITY DR
Second Line	:	STE 115
City	:	MESA
State	:	AZ
Zip	:	85213-8335
Country	:	US
Telephone Number	:	480-969-6762
Fax Number	:	480-833-5739

Provider Business Practice Location Address
First Line	:	2135 E UNIVERSITY DR
Second Line	:	STE 115
City	:	MESA
State	:	AZ
Zip	:	85213-8335
Country	:	US
Telephone Number	:	480-969-6762
Fax Number	:	480-833-5739

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	09/24/2007

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