MEDICARE: GREENLAKE MANAGEMENT, 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	DN19072	FL
2	1223G0001X	General Practice Dentistry	DN19762	FL

General Provider Information

NPI Number	:	1699294132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENLAKE MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	10625 N MILITARY TRL STE 201
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-6548
Country	:	US
Telephone Number	:	561-366-7303
Fax Number	:	561-366-7305

Provider Business Practice Location Address
First Line	:	10625 N MILITARY TRL STE 201
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-6548
Country	:	US
Telephone Number	:	561-366-7303
Fax Number	:	561-366-7305

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JENNIFER LYNN WESTCOTT
Credential	:	DMD
Telephone Number	:	561-366-7303

Provider Enumeration Date	:	09/15/2017
Last Update Date	:	07/21/2022

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