MEDICARE: DR. EDSON GUILLERMO BUSTAMANTE D.M.D.

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	DN0013429	FL

General Provider Information

NPI Number	:	1114949518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDSON GUILLERMO BUSTAMANTE D.M.D.

Provider Business Mailing Address
First Line	:	11944 SHELDON RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-3643
Country	:	US
Telephone Number	:	813-926-2262
Fax Number	:	813-920-2226

Provider Business Practice Location Address
First Line	:	11944 SHELDON RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-3643
Country	:	US
Telephone Number	:	813-926-2262
Fax Number	:	813-920-2226

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	07/08/2007

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