MEDICARE: DR. RICHARD RENNER DANIELSON DDS

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	122300000X	Dentist	5110	FL

General Provider Information

NPI Number	:	1235212853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD RENNER DANIELSON DDS

Provider Business Mailing Address
First Line	:	1325 FLORIDA MALL AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-7731
Country	:	US
Telephone Number	:	407-851-0784
Fax Number	:	407-851-7012

Provider Business Practice Location Address
First Line	:	1325 FLORIDA MALL AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-7731
Country	:	US
Telephone Number	:	407-851-0784
Fax Number	:	407-851-7012

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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