MEDICARE: ECONOMY DENTURES OF LAKE MARY

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	DN8243	FL

General Provider Information

NPI Number	:	1629211735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ECONOMY DENTURES OF LAKE MARY

Provider Business Mailing Address
First Line	:	1680 DUNN AVE
Second Line	:	SUITE 31
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-4782
Country	:	US
Telephone Number	:	904-696-6767
Fax Number	:

Provider Business Practice Location Address
First Line	:	890 S SUN DR
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-2406
Country	:	US
Telephone Number	:	407-333-3508
Fax Number	:	407-804-5189

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. WENDY GAIL KIMBRELL
Credential	:
Telephone Number	:	904-696-6767

Provider Enumeration Date	:	04/20/2009
Last Update Date	:	04/20/2009

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