1891128773 NPI number — PEDIATRIC DENTISTRY OF NEW TAMPA

Table of content: (NPI 1891128773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891128773 NPI number — PEDIATRIC DENTISTRY OF NEW TAMPA

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
PEDIATRIC DENTISTRY OF NEW TAMPA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891128773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5326 PRIMROSE LAKE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33647-3589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-374-0388
Provider Business Mailing Address Fax Number:
813-374-0390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5326 PRIMROSE LAKE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33647-3589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-374-0388
Provider Business Practice Location Address Fax Number:
813-374-0390
Provider Enumeration Date:
08/15/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RIVERA
Authorized Official First Name:
MARTA
Authorized Official Middle Name:
MILAGROS
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
813-374-0388

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  DN19520 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: DN14483 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)