MEDICARE: ADVANCED DENTAL CARE (JACKSONVILLE SOUTH), PLLC

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	:	1619326477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DENTAL CARE (JACKSONVILLE SOUTH), PLLC

Provider Business Mailing Address
First Line	:	13195 SW 134TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-4461
Country	:	US
Telephone Number	:	305-274-2499
Fax Number	:

Provider Business Practice Location Address
First Line	:	3667 CROWN POINT RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-5956
Country	:	US
Telephone Number	:	305-274-2499
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MS. STEPHANIE GOMEZ
Credential	:
Telephone Number	:	305-274-2499

Provider Enumeration Date	:	06/11/2016
Last Update Date	:	06/11/2016

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