MEDICARE: SMILES OF PUNTA GORDA, PA

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

General Provider Information

NPI Number	:	1528701463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILES OF PUNTA GORDA, PA

Provider Business Mailing Address
First Line	:	100 MADRID BLVD UNIT 414
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33950-8929
Country	:	US
Telephone Number	:	941-575-2626
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 MADRID BLVD UNIT 414
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33950-8929
Country	:	US
Telephone Number	:	941-575-2626
Fax Number	:

Authorized Official
Title or Position	:	LEAD OF CREDENTIALING
Name	:	VICENTA REYES
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	04/19/2022
Last Update Date	:	04/19/2022

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