MEDICARE: SAN CARLOS FAMILY DENTAL

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	:	1760754857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN CARLOS FAMILY DENTAL

Provider Business Mailing Address
First Line	:	19004 BIRCH RD
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33967-3603
Country	:	US
Telephone Number	:	239-288-5633
Fax Number	:	239-437-0279

Provider Business Practice Location Address
First Line	:	19004 BIRCH RD
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33967-3603
Country	:	US
Telephone Number	:	239-288-5633
Fax Number	:	239-437-0279

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. TODD SHARP
Credential	:	DMD
Telephone Number	:	239-288-5633

Provider Enumeration Date	:	02/03/2012
Last Update Date	:	02/03/2012

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Directions to “SAN CARLOS FAMILY DENTAL ” Practice Location

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