INTERNATIONAL CENTER FOR COMPLETE DENTISTRY, INC.

Contacts

Phone	+1 727-821-4433
Fax	7278227252

Authorized person

Name	MRS. DREAMA MICHELLE WEGZYN
Role	RN, OFFICE MANAGER
Phone	7278214433

Taxonomy

Taxonomy Code	332BC3200X - Customized Equipment (DME)
License Number	DN4596
State	FL
Is Primary	Yes

Other Provider Identifiers

Issuer	NPI
Number	1477679470
State	FL
Issuer	NPI
Number	1770602567
State	FL
Issuer	PTAN
Number	6301580001
State	FL
Issuer	NPI
Number	1679692461
State	FL
Issuer	NPI
Number	1952426439
State	FL
Issuer	NPI
Number	1295851293
State	FL
Issuer	NPI
Number	1154643377
State	FL

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	1992-05-29
Business code	621210
Sponsor’s telephone number	7278214433
Plan sponsor’s address	111 2ND AVENUE NE, #1104, ST. PETERSBURG, FL, 33701

Plan administrator’s name and address

Administrator’s EIN	591823589
Plan administrator’s name	INTERNATIONAL CENTER FOR COMPLETE DENTISTRY, INC.
Plan administrator’s address	111 2ND AVENUE NE, #1104, ST. PETERSBURG, FL, 33701
Administrator’s telephone number	7278214433

Signature of

Role	Plan administrator
Date	2012-08-23
Name of individual signing	KENNETH GRUNDSET
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	1992-05-29
Business code	621210
Sponsor’s telephone number	7278214433
Plan sponsor’s address	111 2ND AVENUE NE, #1104, ST. PETERSBURG, FL, 33701

Plan administrator’s name and address

Administrator’s EIN	591823589
Plan administrator’s name	INTERNATIONAL CENTER FOR COMPLETE DENTISTRY, INC.
Plan administrator’s address	111 2ND AVENUE NE, #1104, ST. PETERSBURG, FL, 33701
Administrator’s telephone number	7278214433

Signature of

Role	Plan administrator
Date	2011-09-23
Name of individual signing	KENNETH GRUNDSET
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	1992-05-29
Business code	621210
Sponsor’s telephone number	7278214433
Plan sponsor’s address	111 2ND AVENUE NE, #1104, ST. PETERSBURG, FL, 33701

Plan administrator’s name and address

Administrator’s EIN	591823589
Plan administrator’s name	INTERNATIONAL CENTER FOR COMPLETE DENTISTRY, INC.
Plan administrator’s address	111 2ND AVENUE NE, #1104, ST. PETERSBURG, FL, 33701
Administrator’s telephone number	7278214433

Signature of

Role	Plan administrator
Date	2010-09-03
Name of individual signing	KENNETH GRUNDSET
Valid signature	Filed with authorized/valid electronic signature