MEDICARE: AESTHETIC DENTAL GROUP

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	DN17931	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1223G0001X	OTHER	FL	GENERAL PRACTICE ( DENTAL)

General Provider Information

NPI Number	:	1164728200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AESTHETIC DENTAL GROUP

Provider Business Mailing Address
First Line	:	2330 NE 9TH ST
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-3579
Country	:	US
Telephone Number	:	954-563-5535
Fax Number	:	954-563-8888

Provider Business Practice Location Address
First Line	:	2330 NE 9TH ST
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-3579
Country	:	US
Telephone Number	:	954-563-5535
Fax Number	:	954-563-8888

Authorized Official
Title or Position	:	DENTIST
Name	:	MARIA TOIRAC
Credential	:	DDS
Telephone Number	:	954-563-5535

Provider Enumeration Date	:	02/08/2011
Last Update Date	:	02/08/2011

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Directions to “AESTHETIC DENTAL GROUP ” Practice Location

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