Provider Demographics
NPI:1376823781
Name:DENTAL SERVICES OF TOWN AND COUNTRY, PA
Entity Type:Organization
Organization Name:DENTAL SERVICES OF TOWN AND COUNTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:OTERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-606-1232
Mailing Address - Street 1:13776 SW 152ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-1163
Mailing Address - Country:US
Mailing Address - Phone:305-255-8855
Mailing Address - Fax:
Practice Address - Street 1:13776 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-1163
Practice Address - Country:US
Practice Address - Phone:305-255-8855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10814122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL077828102Medicaid