Provider Demographics
NPI:1497769574
Name:BROWN, TED W SR (DDS)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:W
Last Name:BROWN
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 E KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3511
Mailing Address - Country:US
Mailing Address - Phone:813-307-8015
Mailing Address - Fax:813-279-2999
Practice Address - Street 1:1105 E KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-3511
Practice Address - Country:US
Practice Address - Phone:813-307-8015
Practice Address - Fax:813-279-2999
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN3722122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0706981 00Medicaid
FLT94632Medicare UPIN
FL0706981 00Medicaid