Provider Demographics
NPI:1225327430
Name:KOOL KIDZ PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:KOOL KIDZ PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PED. DENTIST/MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:AVES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-885-4501
Mailing Address - Street 1:7712 W WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1813
Mailing Address - Country:US
Mailing Address - Phone:813-885-4501
Mailing Address - Fax:813-885-5410
Practice Address - Street 1:7712 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1813
Practice Address - Country:US
Practice Address - Phone:813-885-4501
Practice Address - Fax:813-885-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN187941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty