MEDICARE: SAND MINE DENTISTRY, PLLC

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

General Provider Information

NPI Number	:	1255025235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAND MINE DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	49591 HIGHWAY 27 STE 301
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33897-9507
Country	:	US
Telephone Number	:	6
Fax Number	:

Provider Business Practice Location Address
First Line	:	49591 HIGHWAY 27 STE 301
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33897-9507
Country	:	US
Telephone Number	:	6
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PETER KELLY
Credential	:
Telephone Number	:	407-432-6224

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	06/05/2023

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