MEDICARE: DENTISTS OF KISSIMMEE, PA

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	:	1124824156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTS OF KISSIMMEE, PA

Provider Business Mailing Address
First Line	:	PO BOX 660041
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75266-0041
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2942 N. ORANGE BLOSSOM TRAIL
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741
Country	:	US
Telephone Number	:	689-223-5412
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BROOKE E KOVINSKY
Credential	:	DDS
Telephone Number	:	714-845-8500

Provider Enumeration Date	:	02/20/2025
Last Update Date	:	02/05/2026

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