MEDICARE: TLC DENTAL - ORTHODONTICS, LLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1932625035
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TLC DENTAL - ORTHODONTICS, LLC

Provider Business Mailing Address
First Line	:	1001 W CYPRESS CREEK RD STE 300
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33309-1950
Country	:	US
Telephone Number	:	954-494-8502
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 E COMMERCIAL BLVD
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-4311
Country	:	US
Telephone Number	:	954-491-7100
Fax Number	:	954-771-6434

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	STEVEN MUCKEY
Credential	:	DDS
Telephone Number	:	954-494-8502

Provider Enumeration Date	:	08/21/2017
Last Update Date	:	08/21/2017

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