MEDICARE: DR. KELLY M DAINIAK DMD

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	122300000X	Dentist	DN15549	FL

General Provider Information

NPI Number	:	1659705085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY M DAINIAK DMD

Provider Business Mailing Address
First Line	:	24600 S TAMIAMI TRL
Second Line	:	STE 206
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-7022
Country	:	US
Telephone Number	:	239-949-8302
Fax Number	:	239-949-8374

Provider Business Practice Location Address
First Line	:	24600 S TAMIAMI TRL
Second Line	:	STE 206
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-7022
Country	:	US
Telephone Number	:	239-949-8302
Fax Number	:	239-949-8374

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2013
Last Update Date	:	08/21/2013

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