MEDICARE: BAYSHORE FAMILY DENTAL PA

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	:	1609576693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSHORE FAMILY DENTAL PA

Provider Business Mailing Address
First Line	:	19787 MORSANI RD
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33558-3320
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1952 BAYSHORE BLVD
Second Line	:
City	:	DUNEDIN
State	:	FL
Zip	:	34698-2500
Country	:	US
Telephone Number	:	727-733-1175
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	SURA DABBAGH
Credential	:	DDS
Telephone Number	:	603-892-7938

Provider Enumeration Date	:	03/08/2023
Last Update Date	:	03/08/2023

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