MEDICARE: SQUARE ONE DENTISTRY 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1831736800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SQUARE ONE DENTISTRY LLC

Provider Business Mailing Address
First Line	:	3571 NW FEDERAL HIGHWAY
Second Line	:
City	:	JENSON BEACH
State	:	FL
Zip	:	34957
Country	:	US
Telephone Number	:	786-457-3690
Fax Number	:

Provider Business Practice Location Address
First Line	:	3571 NW FEDERAL HWY
Second Line	:
City	:	JENSEN BEACH
State	:	FL
Zip	:	34957-4454
Country	:	US
Telephone Number	:	786-457-3690
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NAVED FATMI
Credential	:	DMD
Telephone Number	:	786-457-3690

Provider Enumeration Date	:	12/09/2019
Last Update Date	:	12/09/2019

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