MEDICARE: PEDIATRIC DENTISTRY OF NEW TAMPA

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	1223P0221X	Pediatric Dentistry	DN19520	FL
2	1223P0221X	Pediatric Dentistry	DN14483	FL

General Provider Information

NPI Number	:	1891128773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTISTRY OF NEW TAMPA

Provider Business Mailing Address
First Line	:	5326 PRIMROSE LAKE CIR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3589
Country	:	US
Telephone Number	:	813-374-0388
Fax Number	:	813-374-0390

Provider Business Practice Location Address
First Line	:	5326 PRIMROSE LAKE CIR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3589
Country	:	US
Telephone Number	:	813-374-0388
Fax Number	:	813-374-0390

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. MARTA MILAGROS RIVERA
Credential	:	D.M.D.
Telephone Number	:	813-374-0388

Provider Enumeration Date	:	08/15/2013
Last Update Date	:	08/15/2013

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Directions to “PEDIATRIC DENTISTRY OF NEW TAMPA ” Practice Location

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