Provider Demographics
NPI:1437332616
Name:GAETA DENTAL HEALTH PROFESSIONALS, PA
Entity Type:Organization
Organization Name:GAETA DENTAL HEALTH PROFESSIONALS, PA
Other - Org Name:GAETA DENTAL - VENICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INS COORD
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:609 TAMIAMI TRL S
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3237
Mailing Address - Country:US
Mailing Address - Phone:941-480-1087
Mailing Address - Fax:941-480-1916
Practice Address - Street 1:609 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3237
Practice Address - Country:US
Practice Address - Phone:941-480-1087
Practice Address - Fax:941-480-1916
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GAETA DENTAL HEALTH PROFESSIONALS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty