MEDICARE: DR. FERNANDO O SAN JUAN, SR 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	122300000X	Dentist	DN11002	FL

General Provider Information

NPI Number	:	1568737625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FERNANDO O SAN JUAN, SR D.D.S.

Provider Business Mailing Address
First Line	:	6882 CORAL WAY
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-1704
Country	:	US
Telephone Number	:	305-662-8995
Fax Number	:	305-666-7150

Provider Business Practice Location Address
First Line	:	6882 CORAL WAY
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-1704
Country	:	US
Telephone Number	:	305-662-8995
Fax Number	:	305-666-7150

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

Provider Enumeration Date	:	03/21/2012
Last Update Date	:	03/21/2012

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