MEDICARE: PUNTA GORDA DENTAL CARE

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	:	1144157512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUNTA GORDA DENTAL CARE

Provider Business Mailing Address
First Line	:	3448 CLEVELAND AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7108
Country	:	US
Telephone Number	:	239-936-3436
Fax Number	:

Provider Business Practice Location Address
First Line	:	428 E OLYMPIA AVE
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33950-3836
Country	:	US
Telephone Number	:	941-639-8030
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	TAMMIE STEPHENS
Credential	:
Telephone Number	:	239-936-3436

Provider Enumeration Date	:	05/07/2026
Last Update Date	:	05/07/2026

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