MEDICARE: DR. JACQUELINE KORMANN 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	1223G0001X	General Practice Dentistry	HAD 16	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	59-2420282	OTHER		TAX ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346214889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE KORMANN DDS

Provider Business Mailing Address
First Line	:	PO BOX 1137
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32902-1137
Country	:	US
Telephone Number	:	321-952-9696
Fax Number	:	321-952-7937

Provider Business Practice Location Address
First Line	:	220 BARTON BLVD UNIT C14
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-2742
Country	:	US
Telephone Number	:	321-433-8350
Fax Number	:	321-433-8351

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

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	07/21/2022

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