Provider Demographics
NPI:1497267942
Name:FAMILY DENTISTRY OF PORT CHARLOTTE
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF PORT CHARLOTTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KRAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-773-9344
Mailing Address - Street 1:2300 TAMIAMI TRL # 13&14
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-3900
Mailing Address - Country:US
Mailing Address - Phone:941-209-5959
Mailing Address - Fax:941-866-6838
Practice Address - Street 1:2300 TAMIAMI TRL # 13&14
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-3900
Practice Address - Country:US
Practice Address - Phone:941-209-5353
Practice Address - Fax:941-866-6838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN183101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty