MEDICARE: VBDC OF LAKE PARK PLLC

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	:	1861964116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VBDC OF LAKE PARK PLLC

Provider Business Mailing Address
First Line	:	225 N MACON ST
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31210-6562
Country	:	US
Telephone Number	:	478-733-0857
Fax Number	:	478-254-5709

Provider Business Practice Location Address
First Line	:	101 N CONGRESS AVE
Second Line	:
City	:	LAKE PARK
State	:	FL
Zip	:	33403-3804
Country	:	US
Telephone Number	:	478-733-0857
Fax Number	:	478-254-5709

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PAUL JASON MANN
Credential	:	DMD
Telephone Number	:	478-733-0857

Provider Enumeration Date	:	12/27/2018
Last Update Date	:	12/27/2018

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