MEDICARE: DR. ALFRED JOSE MORA D.D.S.

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	DN0011851	FL

General Provider Information

NPI Number	:	1447473897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALFRED JOSE MORA D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 3629
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34948-3629
Country	:	US
Telephone Number	:	772-464-2300
Fax Number	:	772-464-2322

Provider Business Practice Location Address
First Line	:	221 S 6TH ST
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-4223
Country	:	US
Telephone Number	:	772-464-2300
Fax Number	:	772-464-2322

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

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	10/24/2013

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