MEDICARE: PONTE VEDRA FAMILY DENTISTRY

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	DN16658	FL

General Provider Information

NPI Number	:	1588823033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONTE VEDRA FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	7000 SAWGRASS VILLAGE CIR
Second Line	:	SUITE 326
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-5014
Country	:	US
Telephone Number	:	904-280-1200
Fax Number	:	904-280-0001

Provider Business Practice Location Address
First Line	:	7000 SAWGRASS VILLAGE CIR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-5014
Country	:	US
Telephone Number	:	904-280-1200
Fax Number	:	904-280-0001

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. GEOFFREY A. BANGA
Credential	:	DDS
Telephone Number	:	904-280-1200

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	02/22/2012

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