1942492806 NPI number — FT MYERS DENTAL SERVICE PA

Table of content: (NPI 1942492806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942492806 NPI number — FT MYERS DENTAL SERVICE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FT MYERS DENTAL SERVICE 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 ORTHODONTICS OF FT MYERS
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:
1942492806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6150 DIAMOND CENTER COURT
Provider Second Line Business Mailing Address:
BLDG 300, SUITE 2
Provider Business Mailing Address City Name:
FT. MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-768-2485
Provider Business Mailing Address Fax Number:
239-433-5557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6150 DIAMOND CENTRE CT
Provider Second Line Business Practice Location Address:
BLDG 300, SUITE 2
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33912-4365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-768-2485
Provider Business Practice Location Address Fax Number:
239-433-5557
Provider Enumeration Date:
08/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARRISH
Authorized Official First Name:
MELODY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
305-274-2499

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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