MEDICARE: MECKLER DENTAL PROVIDERS (GROVE CITY), INC.

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
2	1223P0221X	Pediatric Dentistry
3	1223P0300X	Periodontics
4	1223P0700X	Prosthodontics
5	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
6	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
7	1223E0200X	Endodontics
8	1223G0001X	General Practice Dentistry	30.017994	OH
9	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1932377314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MECKLER DENTAL PROVIDERS (GROVE CITY), INC.

Provider Business Mailing Address
First Line	:	7160 DALLAS PKWY STE 400
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-7111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4168 BUCKEYE PKWY
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-8175
Country	:	US
Telephone Number	:	614-801-5620
Fax Number	:	216-584-1024

Authorized Official
Title or Position	:	MANAGER CREDENTIALING
Name	:	RACHEL NITTINGER
Credential	:
Telephone Number	:	972-755-0816

Provider Enumeration Date	:	02/19/2008
Last Update Date	:	02/08/2018

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