MEDICARE: STEPHANIE A AVERY RDH

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	124Q00000X	Dental Hygienist	DH12491	FL

General Provider Information

NPI Number	:	1356946404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE A AVERY RDH

Provider Business Mailing Address
First Line	:	1166 SW MAIN BLVD
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-5780
Country	:	US
Telephone Number	:	867-527-3733
Fax Number	:	386-487-1265

Provider Business Practice Location Address
First Line	:	1166 SW MAIN BLVD
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-5780
Country	:	US
Telephone Number	:	386-752-7373
Fax Number	:	386-487-1265

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

Provider Enumeration Date	:	12/04/2020
Last Update Date	:	12/04/2020

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