1477864528 NPI number — TOWNCARE DENTAL OF BONITA SPRINGS, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477864528 NPI number — TOWNCARE DENTAL OF BONITA SPRINGS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOWNCARE DENTAL OF BONITA SPRINGS, PA
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:
MAIN STREET CHILDREN'S DENTISTRY OF BONITA SPRINGS
Provider Other Organization Name Type Code:
3
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:
1477864528
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13195 SW 134TH ST
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33186-4461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-274-2499
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16565 VANDERBILT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONITA SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34134-7552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-322-1262
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GOBER
Authorized Official First Name:
MELVYN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
305-274-2499

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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