MEDICARE: ONSITE DENTAL RESPONSE 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	124Q00000X	Dental Hygienist
2	122300000X	Dentist

General Provider Information

NPI Number	:	1972752830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONSITE DENTAL RESPONSE LLC.

Provider Business Mailing Address
First Line	:	1205 N.DIXIE HWY.
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-2122
Country	:	US
Telephone Number	:	561-802-4446
Fax Number	:	561-802-9997

Provider Business Practice Location Address
First Line	:	1205 N.DIXIE HWY.
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-2122
Country	:	US
Telephone Number	:	561-802-4446
Fax Number	:	561-802-9997

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS ANTHONY DEMERE
Credential	:
Telephone Number	:	561-802-4446

Provider Enumeration Date	:	09/16/2008
Last Update Date	:	09/16/2008

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