Provider Demographics
NPI:1275036642
Name:DESTIN DENTAL GROUP
Entity Type:Organization
Organization Name:DESTIN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROOTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-234-7080
Mailing Address - Street 1:10510 HUTCHISON BLVD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3836
Mailing Address - Country:US
Mailing Address - Phone:850-234-7080
Mailing Address - Fax:
Practice Address - Street 1:10510 HUTCHISON BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-3836
Practice Address - Country:US
Practice Address - Phone:850-234-7080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17955261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental