Provider Demographics
NPI:1174850093
Name:MAIN STREET CHILDREN'S DENTISTRY & ORTHODONTICS OF PALMETTO BAY, PA
Entity Type:Organization
Organization Name:MAIN STREET CHILDREN'S DENTISTRY & ORTHODONTICS OF PALMETTO BAY, PA
Other - Org Name:MAIN STREET CHILDREN'S DENISTRY OF PALMETTO BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:13195 SW 134 ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186
Mailing Address - Country:US
Mailing Address - Phone:305-274-2499
Mailing Address - Fax:305-251-9989
Practice Address - Street 1:8805 SW 144TH ST
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33176-7218
Practice Address - Country:US
Practice Address - Phone:305-253-6944
Practice Address - Fax:305-251-9989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty