MEDICARE: DR. VIRGIL ULLOM 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	1223G0001X	General Practice Dentistry	DN9072	FL

General Provider Information

NPI Number	:	1710021415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIRGIL ULLOM D.D.S.

Provider Business Mailing Address
First Line	:	245 BABSON DR
Second Line	:
City	:	BABSON PARK
State	:	FL
Zip	:	33827-9516
Country	:	US
Telephone Number	:	863-638-2228
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 SCENIC CENTRAL STE 107
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33853-6107
Country	:	US
Telephone Number	:	863-678-1939
Fax Number	:

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

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/09/2007

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