MEDICARE: ILONA FOTEK D.M.D,M.S.

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	DN17982	FL

General Provider Information

NPI Number	:	1053519041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILONA FOTEK D.M.D,M.S.

Provider Business Mailing Address
First Line	:	111 LA VIDA CT
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-1720
Country	:	US
Telephone Number	:	561-779-7058
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 FORUM WAY STE 800
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-2322
Country	:	US
Telephone Number	:	561-327-6664
Fax Number	:

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

Provider Enumeration Date	:	07/11/2007
Last Update Date	:	11/10/2010

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