Provider Demographics
NPI:1174284806
Name:CDPG, P.A.
Entity Type:Organization
Organization Name:CDPG, P.A.
Other - Org Name:RIVER BREEZE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:5201 BABCOCK ST NE STE 4
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4637
Mailing Address - Country:US
Mailing Address - Phone:321-722-4400
Mailing Address - Fax:
Practice Address - Street 1:5201 BABCOCK ST NE STE 4
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4637
Practice Address - Country:US
Practice Address - Phone:321-722-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CDPG, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-05
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty