MEDICARE: PENSACOLA EDC MANAGEMENT LLC

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

General Provider Information

NPI Number	:	1225850993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENSACOLA EDC MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	PO BOX 1740
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68005-1740
Country	:	US
Telephone Number	:	402-658-4687
Fax Number	:

Provider Business Practice Location Address
First Line	:	3101 W MICHIGAN AVE STE E
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32526-1876
Country	:	US
Telephone Number	:	850-792-1841
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL OBENG
Credential	:
Telephone Number	:	402-981-4136

Provider Enumeration Date	:	10/24/2024
Last Update Date	:	10/24/2024

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