MEDICARE: TLC DENTAL - FT. LAUDERDALE, 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

General Provider Information

NPI Number	:	1053444869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TLC DENTAL - FT. LAUDERDALE, LLC

Provider Business Mailing Address
First Line	:	15 SARANAC RD
Second Line	:
City	:	SEA RANCH LAKES
State	:	FL
Zip	:	33308-2910
Country	:	US
Telephone Number	:	954-650-1122
Fax Number	:	954-786-2726

Provider Business Practice Location Address
First Line	:	3001 E COMMERCIAL BLVD
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-4311
Country	:	US
Telephone Number	:	954-491-7100
Fax Number	:	954-771-6434

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEVEN D MUCKEY
Credential	:	DDS
Telephone Number	:	954-650-1122

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	09/06/2016

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