MEDICARE: DR. SERGE MOLDAVSKY D.M.D.

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	062467-01	NY
2	1223G0001X	General Practice Dentistry	DI19744	NJ
3	1223G0001X	General Practice Dentistry	DN29301	FL

General Provider Information

NPI Number	:	1396894630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SERGE MOLDAVSKY D.M.D.

Provider Business Mailing Address
First Line	:	14653 NEWTONMORE LN
Second Line	:
City	:	LAKEWOOD RANCH
State	:	FL
Zip	:	34202-5641
Country	:	US
Telephone Number	:	973-787-4029
Fax Number	:

Provider Business Practice Location Address
First Line	:	560 N WASHINGTON BLVD STE B
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34236-4253
Country	:	US
Telephone Number	:	973-787-4029
Fax Number	:

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

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	12/23/2024

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