MEDICARE: DENTAL EXCELLENCE AT FISHHAWK

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	122300000X	Dentist	DN15191	FL

General Provider Information

NPI Number	:	1952502742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL EXCELLENCE AT FISHHAWK

Provider Business Mailing Address
First Line	:	5486 LITHIA PINECREST RD
Second Line	:
City	:	LITHIA
State	:	FL
Zip	:	33547-2853
Country	:	US
Telephone Number	:	813-571-5555
Fax Number	:	813-571-5559

Provider Business Practice Location Address
First Line	:	5486 LITHIA PINECREST RD
Second Line	:
City	:	LITHIA
State	:	FL
Zip	:	33547-2853
Country	:	US
Telephone Number	:	813-571-5555
Fax Number	:	813-571-5559

Authorized Official
Title or Position	:	DMD
Name	:	DR. RICHARD MICHAEL KERNAGIS
Credential	:
Telephone Number	:	813-571-5555

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	07/10/2008

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