Provider Demographics
NPI:1295194579
Name:AFFORDABLE DENTURES - PORT ST. LUCIE III, P.A.
Entity Type:Organization
Organization Name:AFFORDABLE DENTURES - PORT ST. LUCIE III, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD/PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-398-7790
Mailing Address - Street 1:9140 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3485
Mailing Address - Country:US
Mailing Address - Phone:772-398-7790
Mailing Address - Fax:
Practice Address - Street 1:9140 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3485
Practice Address - Country:US
Practice Address - Phone:772-398-7790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty