MEDICARE: DYNAMIC LIVES

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	:	1255191300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC LIVES

Provider Business Mailing Address
First Line	:	464 S RIDGEWOOD AVE
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-4928
Country	:	US
Telephone Number	:	386-255-8866
Fax Number	:

Provider Business Practice Location Address
First Line	:	464 S RIDGEWOOD AVE
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-4928
Country	:	US
Telephone Number	:	386-255-8866
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RAMANPREET KAUR RANDHAWA-KOHLI
Credential	:	DDS
Telephone Number	:	386-334-6085

Provider Enumeration Date	:	03/19/2024
Last Update Date	:	03/19/2024

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1245951821 — DR. RAMANPREET KAUR RANDHAWA-KOHLI DDS
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Directions to “DYNAMIC LIVES ” Practice Location

Language	Start Address	Practice Location

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