MEDICARE: DR. I WARREN HERSCH 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	8790	FL

General Provider Information

NPI Number	:	1164442695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. I WARREN HERSCH D.M.D.

Provider Business Mailing Address
First Line	:	823 DUNLAWTON AVE
Second Line	:	SUITE E
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4220
Country	:	US
Telephone Number	:	386-763-9413
Fax Number	:	386-763-5833

Provider Business Practice Location Address
First Line	:	823 DUNLAWTON AVE
Second Line	:	SUITE E
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4220
Country	:	US
Telephone Number	:	386-763-9413
Fax Number	:	386-763-5833

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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