MEDICARE: DR. DOUGLAS G. GENNINGER D.D.S.

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	9851	FL

General Provider Information

NPI Number	:	1235333469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS G. GENNINGER D.D.S.

Provider Business Mailing Address
First Line	:	19114 AVENUE BAYONNES
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33558-5358
Country	:	US
Telephone Number	:	813-949-2234
Fax Number	:

Provider Business Practice Location Address
First Line	:	1305 W FLETCHER AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33612-3310
Country	:	US
Telephone Number	:	813-968-4808
Fax Number	:	813-968-3439

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

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	07/08/2007

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