MEDICARE: MIDWAY DENTAL CENTER OF FT PIERCE 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	122300000X	Dentist	FL006163	FL

General Provider Information

NPI Number	:	1992972442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWAY DENTAL CENTER OF FT PIERCE LLC

Provider Business Mailing Address
First Line	:	5054 S 25TH ST
Second Line	:
City	:	FT PIERCE
State	:	FL
Zip	:	34981
Country	:	US
Telephone Number	:	772-464-4822
Fax Number	:	772-464-8656

Provider Business Practice Location Address
First Line	:	5054 S 25TH ST
Second Line	:
City	:	FT PIERCE
State	:	FL
Zip	:	34981
Country	:	US
Telephone Number	:	772-464-4822
Fax Number	:	772-464-8656

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAMES LOWELL STRAWN
Credential	:	DDS
Telephone Number	:	772-464-4822

Provider Enumeration Date	:	05/14/2008
Last Update Date	:	05/14/2008

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