Provider Demographics
NPI:1013376219
Name:MIDBAY DENTAL PPLC
Entity Type:Organization
Organization Name:MIDBAY DENTAL PPLC
Other - Org Name:MID BAY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:KONANE
Authorized Official - Last Name:CHASE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-897-4200
Mailing Address - Street 1:4579 E HIGHWAY 20 STE 210
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-9810
Mailing Address - Country:US
Mailing Address - Phone:850-897-4200
Mailing Address - Fax:850-897-4504
Practice Address - Street 1:4579 E HIGHWAY 20 STE 210
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-9810
Practice Address - Country:US
Practice Address - Phone:850-897-4200
Practice Address - Fax:850-897-4504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1841210267OtherINDIVIDUAL