Provider Demographics
NPI:1497082796
Name:COUNTRY CLUB DENTAL CARE
Entity Type:Organization
Organization Name:COUNTRY CLUB DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:WARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-269-1242
Mailing Address - Street 1:214 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-8605
Mailing Address - Country:US
Mailing Address - Phone:321-269-1242
Mailing Address - Fax:321-269-4477
Practice Address - Street 1:214 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-8605
Practice Address - Country:US
Practice Address - Phone:321-269-1242
Practice Address - Fax:321-269-4477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11533122300000X
FL9681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty