MEDICARE: MCILWAIN DENTAL SPECIALISTS

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	1223P0221X	Pediatric Dentistry	14465	FL

General Provider Information

NPI Number	:	1386648863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCILWAIN DENTAL SPECIALISTS

Provider Business Mailing Address
First Line	:	4710 N HABANA AVE
Second Line	:	STE 203
City	:	TAMPA
State	:	FL
Zip	:	33614-7146
Country	:	US
Telephone Number	:	813-879-8097
Fax Number	:	813-875-8792

Provider Business Practice Location Address
First Line	:	4710 N HABANA AVE
Second Line	:	STE 203
City	:	TAMPA
State	:	FL
Zip	:	33614-7146
Country	:	US
Telephone Number	:	813-879-8097
Fax Number	:	813-875-8792

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LEIGH ANN MCILWAIN
Credential	:	DMD
Telephone Number	:	813-879-8097

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	01/22/2019

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1508045774 — DR. LOURDES U LORETO MD
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