Provider Demographics
NPI:1023189693
Name:YOUR DENTIST INC
Entity Type:Organization
Organization Name:YOUR DENTIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT OF CORP DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:MACCARO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-760-5511
Mailing Address - Street 1:310 BELLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119
Mailing Address - Country:US
Mailing Address - Phone:386-760-5511
Mailing Address - Fax:386-760-7848
Practice Address - Street 1:310 BELLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119
Practice Address - Country:US
Practice Address - Phone:386-760-5511
Practice Address - Fax:386-760-7848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty