MEDICARE: BANYAN DENTAL GROUP, L.L.C.

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

General Provider Information

NPI Number	:	1477672475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANYAN DENTAL GROUP, L.L.C.

Provider Business Mailing Address
First Line	:	1820 58TH AVE
Second Line	:	SUITE 101
City	:	VERO BEACH
State	:	FL
Zip	:	32966-4673
Country	:	US
Telephone Number	:	772-567-2132
Fax Number	:

Provider Business Practice Location Address
First Line	:	1820 58TH AVE
Second Line	:	SUITE 101
City	:	VERO BEACH
State	:	FL
Zip	:	32966-4673
Country	:	US
Telephone Number	:	772-567-2132
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRUCE HOFFMAN
Credential	:	D.D.S.
Telephone Number	:	772-567-2132

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	03/17/2014

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