MEDICARE: DR. ROBERT MA D.D.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	DN 17257	FL

General Provider Information

NPI Number	:	1154391712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT MA D.D.S

Provider Business Mailing Address
First Line	:	2613 SW CADET CIR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-2812
Country	:	US
Telephone Number	:	772-807-2684
Fax Number	:

Provider Business Practice Location Address
First Line	:	3476 NW FEDERAL HWY
Second Line	:
City	:	JENSEN BEACH
State	:	FL
Zip	:	34957-4441
Country	:	US
Telephone Number	:	772-692-4002
Fax Number	:

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

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	07/08/2007

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