MEDICARE: DR. PAUL RUSSELL DURYEA DDS,MS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN0008502	FL

General Provider Information

NPI Number	:	1679538060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL RUSSELL DURYEA DDS,MS

Provider Business Mailing Address
First Line	:	2595 TAMPA RD
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-3131
Country	:	US
Telephone Number	:	727-785-8847
Fax Number	:	727-785-9372

Provider Business Practice Location Address
First Line	:	2595 TAMPA RD
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-3131
Country	:	US
Telephone Number	:	727-785-8847
Fax Number	:	727-785-9372

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

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	07/08/2007

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