Provider Demographics
NPI:1154643377
Name:INTERNATIONAL CENTER FOR COMPLETE DENTISTRY
Entity Type:Organization
Organization Name:INTERNATIONAL CENTER FOR COMPLETE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN, OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DREAMA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WEGZYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-821-4433
Mailing Address - Street 1:111 2ND AVE NE
Mailing Address - Street 2:#1104
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3434
Mailing Address - Country:US
Mailing Address - Phone:727-821-4433
Mailing Address - Fax:727-822-7252
Practice Address - Street 1:111 2ND AVE NE
Practice Address - Street 2:#1104
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3434
Practice Address - Country:US
Practice Address - Phone:727-821-4433
Practice Address - Fax:727-822-7252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN4596332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1477679470OtherNPI
FL1770602567OtherNPI
FL6301580001OtherPTAN
FL1679692461OtherNPI
FL1952426439OtherNPI
FL1295851293OtherNPI
FL1154643377OtherNPI