1790273159 NPI number — MAIN STREET CHILDRENS DENTISTRY AND ORTHODONTICS OF LAKEWOOD RANCH PLL

Table of content: (NPI 1790273159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790273159 NPI number — MAIN STREET CHILDRENS DENTISTRY AND ORTHODONTICS OF LAKEWOOD RANCH PLL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET CHILDRENS DENTISTRY AND ORTHODONTICS OF LAKEWOOD RANCH PLL
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:
1790273159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6240 LAKE OSPREY DR DEPT 50226
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD RANCH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34240-8421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11649 SR 70 EAST, SUITE 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-209-1213
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SUPERVISOR
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)

  • Identifier: 105846600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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