MEDICARE: CROWN DENTAL, INC.

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	DN12639	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770863110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN DENTAL, INC.

Provider Business Mailing Address
First Line	:	4812 N HABANA AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-6871
Country	:	US
Telephone Number	:	813-873-0271
Fax Number	:	813-873-2929

Provider Business Practice Location Address
First Line	:	4812 N HABANA AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-6871
Country	:	US
Telephone Number	:	813-873-0271
Fax Number	:	813-873-2929

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HUGO RUIZ
Credential	:	DOCTOR
Telephone Number	:	813-873-0271

Provider Enumeration Date	:	08/17/2011
Last Update Date	:	08/17/2011

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