MEDICARE: INTEGRAL DENTAL, INC.

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	:	1659514479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRAL DENTAL, INC.

Provider Business Mailing Address
First Line	:	2311 10TH AVE N STE 14
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-6605
Country	:	US
Telephone Number	:	561-253-0158
Fax Number	:	561-540-4430

Provider Business Practice Location Address
First Line	:	2311 10TH AVE N STE 14
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33461-6605
Country	:	US
Telephone Number	:	561-253-0158
Fax Number	:	561-540-4430

Authorized Official
Title or Position	:	MANAGER
Name	:	KENNETH BETANCES
Credential	:
Telephone Number	:	561-386-1096

Provider Enumeration Date	:	04/08/2009
Last Update Date	:	04/08/2009

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