MEDICARE: GENERAL AND IMPLANT DENTISTRY AT THE LANDING

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	DN15549	FL

General Provider Information

NPI Number	:	1578776357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENERAL AND IMPLANT DENTISTRY AT THE LANDING

Provider Business Mailing Address
First Line	:	24600 S TAMIAMI TRL
Second Line	:	SUITE # 206
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-7022
Country	:	US
Telephone Number	:	239-949-8302
Fax Number	:	239-949-8374

Provider Business Practice Location Address
First Line	:	24600 S TAMIAMI TRL
Second Line	:	SUITE # 206
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-7022
Country	:	US
Telephone Number	:	239-949-8302
Fax Number	:	239-949-8374

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. KELLY M DAINIAK
Credential	:	D.M.D.
Telephone Number	:	239-949-8302

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	06/25/2008

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