MEDICARE: AFFORDABLE DENTURES - WEST MELBOURNE, 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	122300000X	Dentist	DN15694	FL

General Provider Information

NPI Number	:	1881146686
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFORDABLE DENTURES - WEST MELBOURNE, P.A.

Provider Business Mailing Address
First Line	:	1529 W NEW HAVEN AVE
Second Line	:
City	:	WEST MELBOURNE
State	:	FL
Zip	:	32904-3927
Country	:	US
Telephone Number	:	321-725-6570
Fax Number	:	321-725-6599

Provider Business Practice Location Address
First Line	:	1529 W NEW HAVEN AVE
Second Line	:
City	:	WEST MELBOURNE
State	:	FL
Zip	:	32904-3927
Country	:	US
Telephone Number	:	321-725-6570
Fax Number	:	321-725-6599

Authorized Official
Title or Position	:	PRACTICE OWNER
Name	:	TIMOTHY LUONG
Credential	:	DDS
Telephone Number	:	321-725-6570

Provider Enumeration Date	:	10/27/2016
Last Update Date	:	10/27/2016

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