MEDICARE: 5TH AVENUE DENTAL PLLC

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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1609446632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5TH AVENUE DENTAL PLLC

Provider Business Mailing Address
First Line	:	1500 N FEDERAL HWY STE 280
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-5600
Country	:	US
Telephone Number	:	561-205-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 N FEDERAL HWY STE 280
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-5600
Country	:	US
Telephone Number	:	561-205-5000
Fax Number	:

Authorized Official
Title or Position	:	PERIODONTIST/OWNER
Name	:	DR. ANDREW FORREST
Credential	:	DDS
Telephone Number	:	561-205-5000

Provider Enumeration Date	:	06/30/2021
Last Update Date	:	06/30/2021

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