Provider Demographics
NPI:1023540721
Name:FAMILY AND COSMETIC DENTISTRY OF TEMPLE TERRACE
Entity Type:Organization
Organization Name:FAMILY AND COSMETIC DENTISTRY OF TEMPLE TERRACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:VIVIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CABRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-988-2729
Mailing Address - Street 1:224 BULLARD PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-5512
Mailing Address - Country:US
Mailing Address - Phone:813-988-2729
Mailing Address - Fax:813-988-8729
Practice Address - Street 1:224 BULLARD PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-5512
Practice Address - Country:US
Practice Address - Phone:813-988-2729
Practice Address - Fax:813-988-8729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-0014538332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071698700Medicaid