MEDICARE: AVALONDENTAL GROUP

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	1223D0001X	Public Health Dentistry	DN17986	FL

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	:	1942556337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVALONDENTAL GROUP

Provider Business Mailing Address
First Line	:	12950 E COLONIAL DR STE 124
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32826-4609
Country	:	US
Telephone Number	:	407-281-1119
Fax Number	:	407-381-3711

Provider Business Practice Location Address
First Line	:	12950 E COLONIAL DR STE 124
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32826-4609
Country	:	US
Telephone Number	:	407-281-1119
Fax Number	:	407-381-3711

Authorized Official
Title or Position	:	DENTIST
Name	:	MRS. NGA K VAN
Credential	:	D.M.D
Telephone Number	:	407-281-1119

Provider Enumeration Date	:	08/03/2012
Last Update Date	:	08/03/2012

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Directions to “AVALONDENTAL GROUP ” Practice Location

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