MEDICARE: TRADITION DENTAL, P.A.

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	:	1801304977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRADITION DENTAL, P.A.

Provider Business Mailing Address
First Line	:	1973 SW SAVAGE BLVD STE 205
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-2791
Country	:	US
Telephone Number	:	772-207-1213
Fax Number	:	772-877-2862

Provider Business Practice Location Address
First Line	:	1973 SW SAVAGE BLVD STE 205
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-2791
Country	:	US
Telephone Number	:	772-207-1213
Fax Number	:	772-877-2862

Authorized Official
Title or Position	:	SECRETARY
Name	:	MINA HARROUFF
Credential	:
Telephone Number	:	561-401-5006

Provider Enumeration Date	:	01/11/2018
Last Update Date	:	01/11/2018

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