MEDICARE: DR. BAS MICHAEL ANTIC GROEN D.D.S.

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	1223E0200X	Endodontics	DN17852	FL
2	1223E0200X	Endodontics	55473	CA
3	1223E0200X	Endodontics	D6709	AZ

General Provider Information

NPI Number	:	1912118118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BAS MICHAEL ANTIC GROEN D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 70341
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33307-0341
Country	:	US
Telephone Number	:	310-569-2651
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 S MILITARY TRL
Second Line	:	SUITE 4
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-3032
Country	:	US
Telephone Number	:	954-725-3717
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2007
Last Update Date	:	05/14/2009

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