MEDICARE: DR. COLLEEN SABOL OLITSKY D.M.D

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	DN 15862	FL

General Provider Information

NPI Number	:	1942507868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COLLEEN SABOL OLITSKY D.M.D

Provider Business Mailing Address
First Line	:	818 A1A N
Second Line	:	SUITE 209
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-3295
Country	:	US
Telephone Number	:	904-273-1723
Fax Number	:	904-273-1726

Provider Business Practice Location Address
First Line	:	818 A1A N
Second Line	:	SUITE 209
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-3295
Country	:	US
Telephone Number	:	904-273-1723
Fax Number	:	904-273-1726

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

Provider Enumeration Date	:	02/14/2011
Last Update Date	:	02/14/2011

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