MEDICARE: MOUNT DORA SMILES 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1891571881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT DORA SMILES PLLC

Provider Business Mailing Address
First Line	:	1581 AMARYLLIS CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-7432
Country	:	US
Telephone Number	:	954-483-8184
Fax Number	:

Provider Business Practice Location Address
First Line	:	19001 US HIGHWAY 441
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-6708
Country	:	US
Telephone Number	:	352-549-9420
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. JENNIFER TRANG VAN
Credential	:	DMD
Telephone Number	:	954-483-8184

Provider Enumeration Date	:	09/05/2023
Last Update Date	:	09/05/2023

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