MEDICARE: LASTING SMILES OF KISSIMMEE LLC

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	:	1598303588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LASTING SMILES OF KISSIMMEE LLC

Provider Business Mailing Address
First Line	:	1135 W COLUMBIA AVE
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-3202
Country	:	US
Telephone Number	:	407-933-4343
Fax Number	:

Provider Business Practice Location Address
First Line	:	1135 W COLUMBIA AVE
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-3202
Country	:	US
Telephone Number	:	407-933-4343
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DHARAM TAYAL
Credential	:
Telephone Number	:	716-239-5889

Provider Enumeration Date	:	12/20/2019
Last Update Date	:	12/20/2019

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