Provider Demographics
NPI:1508241951
Name:HOUSE OF DENTISTRY
Entity Type:Organization
Organization Name:HOUSE OF DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-476-2919
Mailing Address - Street 1:1201 NE 26TH ST
Mailing Address - Street 2:#107
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1206
Mailing Address - Country:US
Mailing Address - Phone:813-476-2919
Mailing Address - Fax:
Practice Address - Street 1:1314 NE 13TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1829
Practice Address - Country:US
Practice Address - Phone:813-476-2919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 18733122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty