Provider Demographics
NPI:1497454946
Name:PEDIATRIC DENTISTRY OF LUTZ, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF LUTZ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-591-2200
Mailing Address - Street 1:4675 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4880
Mailing Address - Country:US
Mailing Address - Phone:813-591-2200
Mailing Address - Fax:813-374-8329
Practice Address - Street 1:4675 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4880
Practice Address - Country:US
Practice Address - Phone:813-591-2200
Practice Address - Fax:813-374-8329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-23
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty