MEDICARE: MENTOR DENTAL CARE - DAVID M. RAIFFE DDS MBA LLC

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

General Provider Information

NPI Number	:	1942690441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENTOR DENTAL CARE - DAVID M. RAIFFE DDS MBA LLC

Provider Business Mailing Address
First Line	:	7259 CENTER ST
Second Line	:
City	:	MENTOR
State	:	OH
Zip	:	44060-4907
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7259 CENTER ST
Second Line	:
City	:	MENTOR
State	:	OH
Zip	:	44060-4907
Country	:	US
Telephone Number	:	440-823-6790
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	OPAL ANDERSON
Credential	:
Telephone Number	:	440-823-6790

Provider Enumeration Date	:	02/04/2015
Last Update Date	:	02/04/2015

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