MEDICARE: DR. MICHAEL DEAN KERSEY 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	122300000X	Dentist	2661	AR

General Provider Information

NPI Number	:	1942319769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL DEAN KERSEY DDS

Provider Business Mailing Address
First Line	:	PO BOX 128
Second Line	:
City	:	MAMMOTH SPRING
State	:	AR
Zip	:	72554-0128
Country	:	US
Telephone Number	:	870-625-3262
Fax Number	:	870-625-3673

Provider Business Practice Location Address
First Line	:	180 MAIN STREET
Second Line	:
City	:	MAMMOTH SPRING
State	:	AR
Zip	:	72554
Country	:	US
Telephone Number	:	870-625-3262
Fax Number	:	870-625-3673

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/09/2007

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