Provider Demographics
NPI:1114446218
Name:SHORE DENTAL, LLC
Entity Type:Organization
Organization Name:SHORE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NOELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-474-9548
Mailing Address - Street 1:1861 PLACIDA RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-4900
Mailing Address - Country:US
Mailing Address - Phone:941-474-9548
Mailing Address - Fax:941-475-6745
Practice Address - Street 1:4901 WHITE IBIS DRIVE
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287
Practice Address - Country:US
Practice Address - Phone:941-474-9548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty