MEDICARE: JOHN ANTONELLI DDS

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	122300000X	Dentist	TPNU053	FL

General Provider Information

NPI Number	:	1316096977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN ANTONELLI DDS

Provider Business Mailing Address
First Line	:	3200 S UNIVERSITY DRIVE
Second Line	:	NOVA SOUTHEASTERN UNIVERSITY COLLEGE OF DENTAL MEDICINE
City	:	FORT LAUDERDALE DAVIE
State	:	FL
Zip	:	33328-2018
Country	:	US
Telephone Number	:	954-262-7348
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 S UNIVERSITY DRIVE
Second Line	:	NOVA SOUTHEASTERN UNIVERSITY COLLEGE OF DENTAL MEDICINE
City	:	FORT LAUDERDALE DAVIE
State	:	FL
Zip	:	33328-2018
Country	:	US
Telephone Number	:	954-262-7348
Fax Number	:

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

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	07/08/2007

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