MEDICARE: CLASSIC 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	122300000X	Dentist	DN11075	FL

General Provider Information

NPI Number	:	1821259383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLASSIC DENTAL, INC.

Provider Business Mailing Address
First Line	:	4267 W LAKE MARY BLVD
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-2411
Country	:	US
Telephone Number	:	407-302-7774
Fax Number	:	407-302-5651

Provider Business Practice Location Address
First Line	:	4267 W LAKE MARY BLVD
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-2411
Country	:	US
Telephone Number	:	407-302-7774
Fax Number	:	407-302-5651

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CEASAR M. GARCIA
Credential	:	D.M.D.
Telephone Number	:	407-302-7774

Provider Enumeration Date	:	06/18/2008
Last Update Date	:	06/18/2008

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