1346764297 NPI number — SEASIDE SMILES PEDIATRIC DENTISTRY, PLLC

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 1346764297 NPI number — SEASIDE SMILES PEDIATRIC DENTISTRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEASIDE SMILES PEDIATRIC DENTISTRY, PLLC
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:
1346764297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3725 12TH CT STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32960-6519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-562-6880
Provider Business Mailing Address Fax Number:
772-562-6895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3725 12TH CT STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-6519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-562-6880
Provider Business Practice Location Address Fax Number:
772-562-6895
Provider Enumeration Date:
08/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
CHELESEA
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
PEDIATRIC DENTIST
Authorized Official Telephone Number:
772-562-6880

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  DN20858 , 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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