Provider Demographics
NPI:1336287812
Name:GENTLE CARE DENTISTRY
Entity Type:Organization
Organization Name:GENTLE CARE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:321-453-7047
Mailing Address - Street 1:400 E MERRITT AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3434
Mailing Address - Country:US
Mailing Address - Phone:321-453-7047
Mailing Address - Fax:321-453-4449
Practice Address - Street 1:400 E MERRITT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3434
Practice Address - Country:US
Practice Address - Phone:321-453-7047
Practice Address - Fax:321-453-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-45411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN-4541OtherSTATE OF FL BOARD OF DENT