MEDICARE: ALTAMONTE SPRINGS DENTAL, PLLC

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN12540	OTHER	FL	STATE LICENSE
2	DN19430	OTHER	FL	STATE LICENSE
3	DN23428	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1679109920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTAMONTE SPRINGS DENTAL, PLLC

Provider Business Mailing Address
First Line	:	499 E CENTRAL PKWY STE 200
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32701-3450
Country	:	US
Telephone Number	:	407-831-3959
Fax Number	:

Provider Business Practice Location Address
First Line	:	499 E CENTRAL PKWY STE 200
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32701-3450
Country	:	US
Telephone Number	:	407-831-3959
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PETER KELLY
Credential	:
Telephone Number	:	410-303-1528

Provider Enumeration Date	:	03/19/2020
Last Update Date	:	03/19/2020

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