MEDICARE: LUMINA DENTAL OF LUTZ, PA

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1952949141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUMINA DENTAL OF LUTZ, PA

Provider Business Mailing Address
First Line	:	2945 GUINEVERE DR
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-5916
Country	:	US
Telephone Number	:	321-431-2208
Fax Number	:

Provider Business Practice Location Address
First Line	:	2425 BRUNELLO TRCE
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33558-7800
Country	:	US
Telephone Number	:	813-381-5858
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN D IVEY
Credential	:	DMD
Telephone Number	:	813-381-5858

Provider Enumeration Date	:	12/18/2019
Last Update Date	:	12/18/2019

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