MEDICARE: BESPOKE SMILES DENTISTRY, PA

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1942036264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BESPOKE SMILES DENTISTRY, PA

Provider Business Mailing Address
First Line	:	5770 WILES RD
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-2156
Country	:	US
Telephone Number	:	954-255-5166
Fax Number	:

Provider Business Practice Location Address
First Line	:	5770 WILES RD
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-2156
Country	:	US
Telephone Number	:	954-255-5166
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GILI LITWACK
Credential	:	DDS
Telephone Number	:	516-342-0308

Provider Enumeration Date	:	09/12/2024
Last Update Date	:	11/07/2024

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