MEDICARE: MTA DENTAL 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	1223G0001X	General Practice Dentistry	DN17962	FL

General Provider Information

NPI Number	:	1043505068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MTA DENTAL LLC

Provider Business Mailing Address
First Line	:	6268 W SAMPLE RD
Second Line	:	UNIT 401
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-3272
Country	:	US
Telephone Number	:	305-484-7879
Fax Number	:

Provider Business Practice Location Address
First Line	:	6268 W SAMPLE RD
Second Line	:	UNIT 401
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-3272
Country	:	US
Telephone Number	:	305-484-7879
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MAYA GEORGES ASSI
Credential	:	DMD
Telephone Number	:	305-484-7879

Provider Enumeration Date	:	06/17/2011
Last Update Date	:	06/17/2011

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Directions to “MTA DENTAL LLC ” Practice Location

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