MEDICARE: WEST COAST ENDODONTICS

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

General Provider Information

NPI Number	:	1942813738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST COAST ENDODONTICS

Provider Business Mailing Address
First Line	:	2654 W LAKE RD
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-3120
Country	:	US
Telephone Number	:	727-787-4005
Fax Number	:	727-490-4421

Provider Business Practice Location Address
First Line	:	2654 W LAKE RD
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-3120
Country	:	US
Telephone Number	:	727-787-4005
Fax Number	:	727-490-4421

Authorized Official
Title or Position	:	FRONT OFFICE MANAGER
Name	:	STACEY BLAINE
Credential	:
Telephone Number	:	727-787-4005

Provider Enumeration Date	:	08/31/2020
Last Update Date	:	08/31/2020

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Directions to “WEST COAST ENDODONTICS ” Practice Location

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