MEDICARE: MONTICCIOLO FAMILY AND SEDATION DENTISTRY, PA

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	014899	FL

General Provider Information

NPI Number	:	1245501410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTICCIOLO FAMILY AND SEDATION DENTISTRY, PA

Provider Business Mailing Address
First Line	:	8327 W HILLSBOROUGH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-3805
Country	:	US
Telephone Number	:	813-885-3345
Fax Number	:	813-885-3117

Provider Business Practice Location Address
First Line	:	8327 W HILLSBOROUGH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-3805
Country	:	US
Telephone Number	:	813-885-3345
Fax Number	:	813-885-3117

Authorized Official
Title or Position	:	OWNER/DR.
Name	:	DR. VINCENT JOSEPH MONTICCIOLO
Credential	:	DDS,MBA
Telephone Number	:	727-422-2801

Provider Enumeration Date	:	01/19/2012
Last Update Date	:	01/19/2012

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