Provider Demographics
NPI:1285200782
Name:IMAGINE ORTHODONTIC STUDIO PLLC
Entity Type:Organization
Organization Name:IMAGINE ORTHODONTIC STUDIO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HESS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:727-743-8307
Mailing Address - Street 1:3595 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4860
Mailing Address - Country:US
Mailing Address - Phone:863-462-4463
Mailing Address - Fax:
Practice Address - Street 1:11502 N 56TH ST
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-2239
Practice Address - Country:US
Practice Address - Phone:863-462-4463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1223X0400XMedicaid