MEDICARE: LEGACY DENTAL

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	305R00000X	Preferred Provider Organization		FL

General Provider Information

NPI Number	:	1861796229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY DENTAL

Provider Business Mailing Address
First Line	:	4993 W ATLANTIC AVE
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-3850
Country	:	US
Telephone Number	:	561-381-3100
Fax Number	:	561-381-3323

Provider Business Practice Location Address
First Line	:	4993 W ATLANTIC AVE
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33445-3850
Country	:	US
Telephone Number	:	561-381-3100
Fax Number	:	561-381-3323

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. CHRIS WITTUSEN
Credential	:
Telephone Number	:	561-381-3100

Provider Enumeration Date	:	12/28/2010
Last Update Date	:	12/28/2010

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Practice Location Address:

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Directions to “LEGACY DENTAL ” Practice Location

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