MEDICARE: LAND O LAKES PEDIATRIC 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1871362632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAND O LAKES PEDIATRIC DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	16688 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-1400
Country	:	US
Telephone Number	:	813-579-8492
Fax Number	:	813-333-7323

Provider Business Practice Location Address
First Line	:	5442 LAND O LAKES BLVD
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34639-3413
Country	:	US
Telephone Number	:	813-579-8492
Fax Number	:	813-333-7323

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MRS. NELLIE LIN
Credential	:
Telephone Number	:	813-579-8492

Provider Enumeration Date	:	12/21/2023
Last Update Date	:	12/21/2023

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