MEDICARE: DR. TANMYA STUTI RAVI D.M.D

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	03791	NH
2	1223G0001X	General Practice Dentistry	DN20033	FL

General Provider Information

NPI Number	:	1508179771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TANMYA STUTI RAVI D.M.D

Provider Business Mailing Address
First Line	:	12300 S SHORE BLVD STE 208
Second Line	:
City	:	WELLINGTON
State	:	FL
Zip	:	33414-6509
Country	:	US
Telephone Number	:	561-204-4494
Fax Number	:

Provider Business Practice Location Address
First Line	:	12300 S SHORE BLVD STE 208
Second Line	:
City	:	WELLINGTON
State	:	FL
Zip	:	33414-6509
Country	:	US
Telephone Number	:	561-204-4494
Fax Number	:

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

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	01/07/2021

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