1740326321 NPI number — FLORIDA AVENUE DENTISTRY, P.A.

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 1740326321 NPI number — FLORIDA AVENUE DENTISTRY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA AVENUE DENTISTRY, P.A.
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:
1740326321
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 91966
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33804-1966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-686-2268
Provider Business Mailing Address Fax Number:
863-603-0688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 N FLORIDA AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-686-2268
Provider Business Practice Location Address Fax Number:
863-603-0688
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PINKSTON
Authorized Official First Name:
JOE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
863-686-2268

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12541 , 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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