Provider Demographics
NPI:1164130522
Name:AGS DENTISTS OF FT. PIERCE
Entity Type:Organization
Organization Name:AGS DENTISTS OF FT. PIERCE
Other - Org Name:MIDWAY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GIOVANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJESUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-340-0116
Mailing Address - Street 1:8794 BOYNTON BEACH BLVD STE 218
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4469
Mailing Address - Country:US
Mailing Address - Phone:561-425-7999
Mailing Address - Fax:
Practice Address - Street 1:5054 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-4923
Practice Address - Country:US
Practice Address - Phone:772-464-4822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental