MEDICARE: CSM DENTAL CENTER CORP

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

General Provider Information

NPI Number	:	1578990362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CSM DENTAL CENTER CORP

Provider Business Mailing Address
First Line	:	5171 SW 8TH ST
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-2474
Country	:	US
Telephone Number	:	305-567-0236
Fax Number	:	305-442-9333

Provider Business Practice Location Address
First Line	:	5171 SW 8TH ST
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-2474
Country	:	US
Telephone Number	:	305-567-0236
Fax Number	:	305-442-9333

Authorized Official
Title or Position	:	REGISTERED AGENT
Name	:	SOL MESA
Credential	:
Telephone Number	:	305-567-0236

Provider Enumeration Date	:	10/11/2013
Last Update Date	:	10/11/2013

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Directions to “CSM DENTAL CENTER CORP ” Practice Location

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