MEDICARE: DR. COURTNEY SEVILLA DMD

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	1223G0001X	General Practice Dentistry	DN21195	FL
2	122300000X	Dentist	DN21195	FL

General Provider Information

NPI Number	:	1023499431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COURTNEY SEVILLA DMD

Provider Business Mailing Address
First Line	:	3420 BAYSIDE LAKES BLVD SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-6894
Country	:	US
Telephone Number	:	321-722-0155
Fax Number	:

Provider Business Practice Location Address
First Line	:	3420 BAYSIDE LAKES BLVD SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-6894
Country	:	US
Telephone Number	:	321-722-0155
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2015
Last Update Date	:	12/17/2020

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