MEDICARE: BEACH DENTAL GROUP, INC

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	DN15016	FL

General Provider Information

NPI Number	:	1487089140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACH DENTAL GROUP, INC

Provider Business Mailing Address
First Line	:	2100 LAKE IDA RD
Second Line	:	A2
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-2442
Country	:	US
Telephone Number	:	561-272-2131
Fax Number	:	561-272-8141

Provider Business Practice Location Address
First Line	:	2100 LAKE IDA RD
Second Line	:	A2
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-2442
Country	:	US
Telephone Number	:	561-272-2131
Fax Number	:	561-272-8141

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. FREDERICK A FOX
Credential	:	DDS
Telephone Number	:	561-272-2131

Provider Enumeration Date	:	09/12/2013
Last Update Date	:	09/12/2013

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