MEDICARE: JEAN PAUL TAVERAS DMD

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	DN22694	FL

General Provider Information

NPI Number	:	1275062358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN PAUL TAVERAS DMD

Provider Business Mailing Address
First Line	:	2211 MOUNTAIN MEADOW WAY
Second Line	:
City	:	VALRICO
State	:	FL
Zip	:	33594-5136
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1251 ARIANA ST
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-1814
Country	:	US
Telephone Number	:	813-420-1950
Fax Number	:

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

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	06/12/2017

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