Provider Demographics
NPI:1093155236
Name:CELEBRITY SMILES DENTAL
Entity Type:Organization
Organization Name:CELEBRITY SMILES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:GAETA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:941-426-1134
Mailing Address - Street 1:13801 TAMIAMI TRL STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-2017
Mailing Address - Country:US
Mailing Address - Phone:941-426-1134
Mailing Address - Fax:941-423-2396
Practice Address - Street 1:13801 TAMIAMI TRL STE B
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2017
Practice Address - Country:US
Practice Address - Phone:941-426-1134
Practice Address - Fax:941-423-2396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN112621223G0001X
FLDN78451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty