MEDICARE: DESTINATION DENTAL GROUP PC

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

General Provider Information

NPI Number	:	1316759905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINATION DENTAL GROUP PC

Provider Business Mailing Address
First Line	:	2455 E SUNRISE BLVD STE 1204
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3115
Country	:	US
Telephone Number	:	616-299-2692
Fax Number	:

Provider Business Practice Location Address
First Line	:	2455 E SUNRISE BLVD STE 1204
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3115
Country	:	US
Telephone Number	:	616-299-2692
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	DAN KELSEY
Credential	:
Telephone Number	:	616-299-2692

Provider Enumeration Date	:	01/22/2025
Last Update Date	:	01/22/2025

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