Provider Demographics
NPI:1235403817
Name:DENTAL ASSOCIATES OF TAMPA
Entity Type:Organization
Organization Name:DENTAL ASSOCIATES OF TAMPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLEDSOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-510-5960
Mailing Address - Street 1:1311 W BUSCH BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-7709
Mailing Address - Country:US
Mailing Address - Phone:813-898-2888
Mailing Address - Fax:
Practice Address - Street 1:1311 W BUSCH BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7709
Practice Address - Country:US
Practice Address - Phone:813-898-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty