MEDICARE: DR. ROBERT TIMOTHY RADEL D.M.D., M.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	1223E0200X	Endodontics	4098	SC
2	1223E0200X	Endodontics	DS030989L	PA
3	1223E0200X	Endodontics	DN17887	FL

General Provider Information

NPI Number	:	1669473120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT TIMOTHY RADEL D.M.D., M.S.

Provider Business Mailing Address
First Line	:	822 A1A N
Second Line	:	SUITE 314
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-3260
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	822 A1A N
Second Line	:	SUITE 314
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-3260
Country	:	US
Telephone Number	:	904-273-5770
Fax Number	:	904-273-5720

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/17/2007

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