Provider Demographics
NPI:1073832176
Name:ITD ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:ITD ASSOCIATES, P.A.
Other - Org Name:INDRIO DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:772-359-8962
Mailing Address - Street 1:499 NW PRIMA VISTA BLVD.
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983
Mailing Address - Country:US
Mailing Address - Phone:772-335-7392
Mailing Address - Fax:888-610-3835
Practice Address - Street 1:4832 N. KINGS HIGHWAY
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34951
Practice Address - Country:US
Practice Address - Phone:772-468-6226
Practice Address - Fax:772-468-6226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty