MEDICARE: MDM OF LAKELAND 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	1223G0001X	General Practice Dentistry	DN18829	FL

General Provider Information

NPI Number	:	1295006641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MDM OF LAKELAND PA

Provider Business Mailing Address
First Line	:	701 S HOWARD AVE STE 106-386
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-2473
Country	:	US
Telephone Number	:	863-709-1903
Fax Number	:

Provider Business Practice Location Address
First Line	:	2153 E COUNTY ROAD 540A
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-3794
Country	:	US
Telephone Number	:	863-709-1903
Fax Number	:	863-709-8833

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEFFREY A MARTIN
Credential	:
Telephone Number	:	863-709-1903

Provider Enumeration Date	:	01/17/2012
Last Update Date	:	01/17/2012

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Directions to “MDM OF LAKELAND PA ” Practice Location

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