MEDICARE: PERIODONTICS OF THE PALM BEACHES, P.A.

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	1223P0300X	Periodontics	5191	FL

General Provider Information

NPI Number	:	1467583229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERIODONTICS OF THE PALM BEACHES, P.A.

Provider Business Mailing Address
First Line	:	1897 PALM BEACH LAKES BLVD
Second Line	:	SUITE 215
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-3507
Country	:	US
Telephone Number	:	561-686-2477
Fax Number	:	561-686-2699

Provider Business Practice Location Address
First Line	:	1897 PALM BEACH LAKES BLVD
Second Line	:	SUITE 215
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-3507
Country	:	US
Telephone Number	:	561-686-2477
Fax Number	:	561-686-2699

Authorized Official
Title or Position	:	OWNER-PERIODONTIST
Name	:	DR. STUART A. FELDMAN
Credential	:	D.D.S.
Telephone Number	:	561-686-2477

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	01/29/2013

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