MEDICARE: BAYSHORE PEDIATRIC DENTISTRY AND ORTHODONTICS PLLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1194500827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSHORE PEDIATRIC DENTISTRY AND ORTHODONTICS PLLC

Provider Business Mailing Address
First Line	:	11941 WANDSWORTH DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-2612
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8002 BEATY GROVE DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-1601
Country	:	US
Telephone Number	:	813-324-1535
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	ERICA VICE
Credential	:
Telephone Number	:	813-324-1535

Provider Enumeration Date	:	08/30/2023
Last Update Date	:	08/30/2023

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