Provider Demographics
NPI:1508255712
Name:SOUTHSHORE ORTHODONTICS PA
Entity Type:Organization
Organization Name:SOUTHSHORE ORTHODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:AHRENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-843-0783
Mailing Address - Street 1:13135 KINGS LAKE DR # 103
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-3960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13135 KINGS LAKE DR # 103
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3960
Practice Address - Country:US
Practice Address - Phone:813-815-0080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL189851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty