MEDICARE: PARK STREET DENTAL

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	DN11980	FL

General Provider Information

NPI Number	:	1154776730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK STREET DENTAL

Provider Business Mailing Address
First Line	:	4911 PARK ST N
Second Line	:	SUITE A
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-2227
Country	:	US
Telephone Number	:	727-548-7733
Fax Number	:	727-548-0015

Provider Business Practice Location Address
First Line	:	4911 PARK ST N
Second Line	:	SUITE A
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-2227
Country	:	US
Telephone Number	:	727-548-7733
Fax Number	:	727-548-0015

Authorized Official
Title or Position	:	OWNER
Name	:	JOSE M GARCIA
Credential	:	DDS
Telephone Number	:	727-548-7733

Provider Enumeration Date	:	05/02/2016
Last Update Date	:	05/02/2016

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Directions to “PARK STREET DENTAL ” Practice Location

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