MEDICARE: MISS MARIVIC BAUTISTA PANOPIO RDH

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	124Q00000X	Dental Hygienist	DH18958	FL

General Provider Information

NPI Number	:	1215166855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARIVIC BAUTISTA PANOPIO RDH

Provider Business Mailing Address
First Line	:	1245 NW 119TH ST
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33167-3231
Country	:	US
Telephone Number	:	305-685-7863
Fax Number	:	305-687-7603

Provider Business Practice Location Address
First Line	:	1245 NW 119TH ST
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33167-3231
Country	:	US
Telephone Number	:	305-685-7863
Fax Number	:	305-687-7603

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

Provider Enumeration Date	:	07/02/2009
Last Update Date	:	07/02/2009

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