MEDICARE: TLC DENTAL - HOLLYWOOD, LLC

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	:	1629525001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TLC DENTAL - HOLLYWOOD, LLC

Provider Business Mailing Address
First Line	:	15 SARANAC RD
Second Line	:
City	:	SEA RANCH LAKES
State	:	FL
Zip	:	33308-2910
Country	:	US
Telephone Number	:	954-650-1122
Fax Number	:

Provider Business Practice Location Address
First Line	:	1718 SHERIDAN ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-2275
Country	:	US
Telephone Number	:	954-650-1122
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. STEVEN D MUCKEY
Credential	:
Telephone Number	:	954-650-1122

Provider Enumeration Date	:	09/02/2016
Last Update Date	:	09/02/2016

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