MEDICARE: DENTAL SPA AT ABACOA

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	:	1215503289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL SPA AT ABACOA

Provider Business Mailing Address
First Line	:	2826 E OAKLAND PARK BLVD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1800
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1155 MAIN ST STE 105
Second Line	:
City	:	JUPITER
State	:	FL
Zip	:	33458-5264
Country	:	US
Telephone Number	:	561-420-8888
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ROBERT RODRIGUEZ
Credential	:
Telephone Number	:	954-776-4720

Provider Enumeration Date	:	06/01/2021
Last Update Date	:	06/01/2021

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Directions to “DENTAL SPA AT ABACOA ” Practice Location

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