1578663993 NPI number — DENTAL HEALTH GROUP

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 1578663993 NPI number — DENTAL HEALTH GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL HEALTH GROUP
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:
DENTAL HEALTH GROUP @ NORTHSIDE
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:
1578663993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20295 NW 2ND AVE
Provider Second Line Business Mailing Address:
210
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33169-2550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-652-6313
Provider Business Mailing Address Fax Number:
305-652-9940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1006 NO FLORIDA AVENUE
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:
33602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-223-3266
Provider Business Practice Location Address Fax Number:
813-224-9330
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRODY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
305-652-6313

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN10219 , 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)





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