MEDICARE: LGB DENTAL, 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

General Provider Information

NPI Number	:	1336454487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LGB DENTAL, LLC

Provider Business Mailing Address
First Line	:	4638 S ORANGE BLOSSOM TRAIL
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32839
Country	:	US
Telephone Number	:	407-251-2223
Fax Number	:	407-251-2226

Provider Business Practice Location Address
First Line	:	4638 S ORANGE BLOSSOM TRL
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32839-1706
Country	:	US
Telephone Number	:	407-251-2223
Fax Number	:	407-251-2226

Authorized Official
Title or Position	:	MGRM
Name	:	LUZ G BOBADILLA
Credential	:
Telephone Number	:	407-251-2223

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	03/08/2016

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