MEDICARE: DENTAL SERVICES OF TOWN AND COUNTRY, PA

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	122300000X	Dentist	DN10814	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376823781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL SERVICES OF TOWN AND COUNTRY, PA

Provider Business Mailing Address
First Line	:	13776 SW 152ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33177-1163
Country	:	US
Telephone Number	:	305-255-8855
Fax Number	:

Provider Business Practice Location Address
First Line	:	13776 SW 152ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33177-1163
Country	:	US
Telephone Number	:	305-255-8855
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. ANTONIO OTERO
Credential	:	DDS
Telephone Number	:	305-606-1232

Provider Enumeration Date	:	08/17/2011
Last Update Date	:	08/17/2011

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