MEDICARE: SUPREME CARE DENTAL ASSOCIATES, LLC

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	DN14459	FL

General Provider Information

NPI Number	:	1952687824
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME CARE DENTAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	7138 S MILITARY TRL
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7812
Country	:	US
Telephone Number	:	561-296-5557
Fax Number	:	561-296-2557

Provider Business Practice Location Address
First Line	:	7138 S MILITARY TRL
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7812
Country	:	US
Telephone Number	:	561-296-5557
Fax Number	:	561-296-2557

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MISS JANE WOMELSDORFF
Credential	:
Telephone Number	:	561-296-5557

Provider Enumeration Date	:	10/24/2011
Last Update Date	:	03/28/2012

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