MEDICARE: JURGITA HERRON

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	17523	FL

General Provider Information

NPI Number	:	1245382977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JURGITA HERRON

Provider Business Mailing Address
First Line	:	3904 W HILLSBOROUGH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-5653
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3904 W HILLSBOROUGH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-5653
Country	:	US
Telephone Number	:	813-871-2804
Fax Number	:

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	07/08/2007

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