MEDICARE: LAKE WALES DENTAL ASSOCIATES

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	DN11827	FL

General Provider Information

NPI Number	:	1942384961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE WALES DENTAL ASSOCIATES

Provider Business Mailing Address
First Line	:	23871 HWY 27
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33859-7811
Country	:	US
Telephone Number	:	863-678-3177
Fax Number	:	863-678-3188

Provider Business Practice Location Address
First Line	:	23871 HWY 27
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33859-7811
Country	:	US
Telephone Number	:	863-678-3177
Fax Number	:	863-678-3188

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID E JUNCA
Credential	:
Telephone Number	:	863-678-3177

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	08/30/2007

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