MEDICARE: W & B 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	122300000X	Dentist	DN16022	FL
2	122300000X	Dentist	10226	FL

General Provider Information

NPI Number	:	1003992488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W & B DENTISTRY PA

Provider Business Mailing Address
First Line	:	1202 SE PORT ST LUCIE BLVD
Second Line	:	SB
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5364
Country	:	US
Telephone Number	:	772-335-3088
Fax Number	:	772-398-0041

Provider Business Practice Location Address
First Line	:	1202 SE PORT ST LUCIE BLVD
Second Line	:	SB
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5364
Country	:	US
Telephone Number	:	772-335-3088
Fax Number	:	772-398-0041

Authorized Official
Title or Position	:	RECEPTIONIST
Name	:	SHARON DOUGHTY
Credential	:
Telephone Number	:	772-335-3088

Provider Enumeration Date	:	10/28/2006
Last Update Date	:	08/22/2020

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Directions to “W & B DENTISTRY PA ” Practice Location

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