MEDICARE: CORAL DENTAL SPECIALISTS LLC

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
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1316402878
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORAL DENTAL SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	11332 WILES RD
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33076-2114
Country	:	US
Telephone Number	:	954-642-1013
Fax Number	:

Provider Business Practice Location Address
First Line	:	11332 WILES RD
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33076-2114
Country	:	US
Telephone Number	:	954-642-1013
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PRATHIMA ADUSUMILLI
Credential	:	DMD, MS
Telephone Number	:	954-642-1013

Provider Enumeration Date	:	02/08/2019
Last Update Date	:	02/08/2019

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