MEDICARE: DENTAL OFFICE OF PALM HARBOR 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1023584174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL OFFICE OF PALM HARBOR INC

Provider Business Mailing Address
First Line	:	3438 TAMPA RD STE 11
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-3530
Country	:	US
Telephone Number	:	727-786-1077
Fax Number	:	727-781-2131

Provider Business Practice Location Address
First Line	:	3438 TAMPA RD STE 11
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-3530
Country	:	US
Telephone Number	:	727-786-1077
Fax Number	:	727-781-2131

Authorized Official
Title or Position	:	OFFICE ADMINSTRATION
Name	:	NIKKI BLANTON
Credential	:
Telephone Number	:	727-738-8845

Provider Enumeration Date	:	10/16/2018
Last Update Date	:	10/16/2018

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Directions to “DENTAL OFFICE OF PALM HARBOR INC ” Practice Location

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