Provider Demographics
NPI:1326754128
Name:TDC OCEAN DENTAL, PLLC
Entity Type:Organization
Organization Name:TDC OCEAN DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMALTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-633-9676
Mailing Address - Street 1:491 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2044
Mailing Address - Country:US
Mailing Address - Phone:772-878-7525
Mailing Address - Fax:772-340-1807
Practice Address - Street 1:491 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2044
Practice Address - Country:US
Practice Address - Phone:772-878-7525
Practice Address - Fax:772-340-1807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental