MEDICARE: DR. MAITE CASANOVA DMD

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	DN 11782	FL

General Provider Information

NPI Number	:	1255676029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAITE CASANOVA DMD

Provider Business Mailing Address
First Line	:	2509 W CREST AVE
Second Line	:	SUITE 4
City	:	TAMPA
State	:	FL
Zip	:	33614-6839
Country	:	US
Telephone Number	:	813-877-4638
Fax Number	:

Provider Business Practice Location Address
First Line	:	2509 W CREST AVE
Second Line	:	SUITE 4
City	:	TAMPA
State	:	FL
Zip	:	33614-6839
Country	:	US
Telephone Number	:	813-877-4638
Fax Number	:

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

Provider Enumeration Date	:	12/05/2012
Last Update Date	:	12/05/2012

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Directions to “ DR. MAITE CASANOVA DMD” Practice Location

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