MEDICARE: DENTISTRY AT TOWN PARK 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	:	1366148942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTRY AT TOWN PARK LLC

Provider Business Mailing Address
First Line	:	4307 E COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-5217
Country	:	US
Telephone Number	:	407-362-7705
Fax Number	:

Provider Business Practice Location Address
First Line	:	4307 E COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-5217
Country	:	US
Telephone Number	:	407-362-7705
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CLEMENT JAMES CONTESTABLE
Credential	:	DMD
Telephone Number	:	321-356-5497

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	01/17/2025

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