MEDICARE: DR. BRANDON TRAMELL MACK D.D.S.

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	DN21070	FL

General Provider Information

NPI Number	:	1659761765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRANDON TRAMELL MACK D.D.S.

Provider Business Mailing Address
First Line	:	1081 A1A BEACH BLVD
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32080-6733
Country	:	US
Telephone Number	:	904-471-3291
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 N 12TH ST
Second Line	:	SUITE 1105
City	:	TAMPA
State	:	FL
Zip	:	33602-3661
Country	:	US
Telephone Number	:	813-397-3632
Fax Number	:

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

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	10/08/2015

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