MEDICARE: ENDODONTIC SPECIALISTS

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	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1487248951
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENDODONTIC SPECIALISTS

Provider Business Mailing Address
First Line	:	5111 EHRLICH RD STE 130
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-2074
Country	:	US
Telephone Number	:	813-964-8833
Fax Number	:	813-964-8883

Provider Business Practice Location Address
First Line	:	3670 HENDERSON BLVD STE B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-4515
Country	:	US
Telephone Number	:	813-871-5900
Fax Number	:	813-875-7701

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	LORY SELLECK
Credential	:
Telephone Number	:	813-964-8833

Provider Enumeration Date	:	02/25/2021
Last Update Date	:	02/25/2021

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