Provider Demographics
NPI:1093401101
Name:KIDS DENTAL PLACE
Entity Type:Organization
Organization Name:KIDS DENTAL PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WITCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-477-1722
Mailing Address - Street 1:3201 E OLIVE RD STE B
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-7237
Mailing Address - Country:US
Mailing Address - Phone:850-477-1722
Mailing Address - Fax:850-476-8108
Practice Address - Street 1:101 4TH AVE STE B
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-2401
Practice Address - Country:US
Practice Address - Phone:850-384-9171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDS DENTAL PLACE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty