Provider Demographics
NPI:1275084345
Name:MAIN STREET CHILDREN'S DENTISTRY OF WELLINGTON
Entity Type:Organization
Organization Name:MAIN STREET CHILDREN'S DENTISTRY OF WELLINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
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 1:11903 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-7644
Mailing Address - Country:US
Mailing Address - Phone:561-459-2733
Mailing Address - Fax:
Practice Address - Street 1:11903 SOUTHERN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-7644
Practice Address - Country:US
Practice Address - Phone:561-459-2733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN223451223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty