MEDICARE: CONWAY OAKS DENTAL

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN19430	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1609402197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONWAY OAKS DENTAL

Provider Business Mailing Address
First Line	:	3221 CONWAY RD STE A
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32812-7354
Country	:	US
Telephone Number	:	407-277-0981
Fax Number	:

Provider Business Practice Location Address
First Line	:	3221 CONWAY RD STE A
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32812-7354
Country	:	US
Telephone Number	:	407-277-0981
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PETER KELLY
Credential	:
Telephone Number	:	410-410-3031

Provider Enumeration Date	:	03/17/2020
Last Update Date	:	03/17/2020

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Directions to “CONWAY OAKS DENTAL ” Practice Location

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