=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346493376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL GAGAOUDAKIS DMD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2008
-----------------------------------------------------
Last Update Date | 11/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 814 A1A N SUITE 102
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082-3271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-686-1576
-----------------------------------------------------
Fax | 904-686-1706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 814 A1A N SUITE 102
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32082-3271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-686-1576
-----------------------------------------------------
Fax | 904-686-1706
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL E GAGAOUDAKIS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 904-686-1576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN17757
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------