MEDICARE: ANNA MARIA ISLAND DENTAL INC.

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	DN12356	FL

General Provider Information

NPI Number	:	1265729172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANNA MARIA ISLAND DENTAL INC.

Provider Business Mailing Address
First Line	:	16528 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-1325
Country	:	US
Telephone Number	:	813-961-0094
Fax Number	:	813-960-8133

Provider Business Practice Location Address
First Line	:	5319 GULF DR
Second Line	:
City	:	HOLMES BEACH
State	:	FL
Zip	:	34217-1742
Country	:	US
Telephone Number	:	941-778-1122
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. ANDREW JACK MARTINEAU
Credential	:	D.M.D.
Telephone Number	:	941-778-1122

Provider Enumeration Date	:	06/30/2011
Last Update Date	:	06/30/2011

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