MEDICARE: RENATO J. AVES, 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

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	:	1881394740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENATO J. AVES, LLC

Provider Business Mailing Address
First Line	:	19445 SHUMARD OAK DR UNIT 101
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34638-7278
Country	:	US
Telephone Number	:	813-909-2354
Fax Number	:

Provider Business Practice Location Address
First Line	:	19445 SHUMARD OAK DR UNIT 101
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34638-7278
Country	:	US
Telephone Number	:	813-909-2354
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	JULIE MARIE WANGELIN
Credential	:
Telephone Number	:	813-885-6555

Provider Enumeration Date	:	03/08/2023
Last Update Date	:	03/09/2023

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