MEDICARE: LAUDERDALE DENTAL LLC

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	13892	GA

General Provider Information

NPI Number	:	1295152254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAUDERDALE DENTAL LLC

Provider Business Mailing Address
First Line	:	PO BOX 3189
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13220-3189
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6783 VETERANS PKWY
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31909-3254
Country	:	US
Telephone Number	:	706-321-3909
Fax Number	:

Authorized Official
Title or Position	:	DMD/OWNER
Name	:	CANDACE LAUDERDALE
Credential	:	DMD
Telephone Number	:	315-454-6000

Provider Enumeration Date	:	03/27/2014
Last Update Date	:	03/27/2014

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