MEDICARE: DR. VICTOR DEA 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	122300000X	Dentist	17632	FL

General Provider Information

NPI Number	:	1326156621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VICTOR DEA DMD

Provider Business Mailing Address
First Line	:	1015 GATEWAY BLVD STE 503
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-8347
Country	:	US
Telephone Number	:	561-369-5430
Fax Number	:	561-369-5431

Provider Business Practice Location Address
First Line	:	1015 GATEWAY BLVD STE 503
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-8347
Country	:	US
Telephone Number	:	561-369-5430
Fax Number	:

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

Provider Enumeration Date	:	08/27/2006
Last Update Date	:	12/15/2014

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