Provider Demographics
NPI:1285843110
Name:HERSTON DENTAL SERVICES, PL
Entity Type:Organization
Organization Name:HERSTON DENTAL SERVICES, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HERSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:941-255-3700
Mailing Address - Street 1:4161 TAMIAMI TRL
Mailing Address - Street 2:SUITE 803
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9204
Mailing Address - Country:US
Mailing Address - Phone:941-255-3700
Mailing Address - Fax:941-764-0812
Practice Address - Street 1:4161 TAMIAMI TRL
Practice Address - Street 2:SUITE 803
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9204
Practice Address - Country:US
Practice Address - Phone:941-255-3700
Practice Address - Fax:941-764-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 163591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty