MEDICARE: DENTAL 192

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	DN17681	FL
2	1223G0001X	General Practice Dentistry	DN17724	FL

General Provider Information

NPI Number	:	1346689791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL 192

Provider Business Mailing Address
First Line	:	100 W NEW HAVEN AVE
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32901-4303
Country	:	US
Telephone Number	:	630-659-5293
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 W NEW HAVEN AVE
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32901-4303
Country	:	US
Telephone Number	:	630-659-5293
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAMES D. ROPPA
Credential	:
Telephone Number	:	630-551-5423

Provider Enumeration Date	:	06/19/2013
Last Update Date	:	06/19/2013

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