MEDICARE: NORTHSTAR DENTAL, INC.

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	DN9275	FL

General Provider Information

NPI Number	:	1801916861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSTAR DENTAL, INC.

Provider Business Mailing Address
First Line	:	1225 N MILITARY TRL
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-6059
Country	:	US
Telephone Number	:	561-721-9992
Fax Number	:	561-686-8948

Provider Business Practice Location Address
First Line	:	1225 N MILITARY TRL
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-6059
Country	:	US
Telephone Number	:	561-721-9992
Fax Number	:	561-686-8948

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RALPH JIMENEZ
Credential	:
Telephone Number	:	561-721-9992

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	08/11/2008

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