MEDICARE: DR. MARK S RICHEY 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	37012	CA

General Provider Information

NPI Number	:	1952636177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK S RICHEY DDS

Provider Business Mailing Address
First Line	:	1442 UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103
Country	:	US
Telephone Number	:	619-297-6104
Fax Number	:	619-297-7531

Provider Business Practice Location Address
First Line	:	1442 UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103
Country	:	US
Telephone Number	:	619-297-6104
Fax Number	:	619-297-7531

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

Provider Enumeration Date	:	10/06/2009
Last Update Date	:	10/06/2009

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