MEDICARE: DENTAL HEAVEN P.A.

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	DN12108	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871861443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL HEAVEN P.A.

Provider Business Mailing Address
First Line	:	135 S US HIGHWAY 27
Second Line	:
City	:	SOUTH BAY
State	:	FL
Zip	:	33493-2213
Country	:	US
Telephone Number	:	561-996-0033
Fax Number	:	561-996-0044

Provider Business Practice Location Address
First Line	:	135 S US HIGHWAY 27
Second Line	:
City	:	SOUTH BAY
State	:	FL
Zip	:	33493-2213
Country	:	US
Telephone Number	:	561-996-0033
Fax Number	:	561-996-0044

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. SILVIA MENENDEZ
Credential	:
Telephone Number	:	561-996-0033

Provider Enumeration Date	:	12/09/2011
Last Update Date	:	12/09/2011

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Directions to “DENTAL HEAVEN P.A. ” Practice Location

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