MEDICARE: PHOENIX ADVANCED INC

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	:	1053488684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX ADVANCED INC

Provider Business Mailing Address
First Line	:	35915 US HWY 27
Second Line	:	SUITE 2B
City	:	HAINES CITY
State	:	FL
Zip	:	33844-3737
Country	:	US
Telephone Number	:	863-422-8338
Fax Number	:	863-422-5268

Provider Business Practice Location Address
First Line	:	35915 US HWY 27
Second Line	:	SUITE 2B
City	:	HAINES CITY
State	:	FL
Zip	:	33844-3737
Country	:	US
Telephone Number	:	863-422-8338
Fax Number	:	863-422-5268

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAMES P COSTELLO
Credential	:	DDS
Telephone Number	:	352-408-1400

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	08/22/2020

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