Provider Demographics
NPI:1508995242
Name:L. CARL DE JONGH, D.D.S., P.A.
Entity Type:Organization
Organization Name:L. CARL DE JONGH, D.D.S., P.A.
Other - Org Name:MANATEE ENDODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:L.
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:DE JONGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:941-792-4166
Mailing Address - Street 1:2111 59TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7015
Mailing Address - Country:US
Mailing Address - Phone:941-792-4166
Mailing Address - Fax:941-792-5435
Practice Address - Street 1:2111 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7015
Practice Address - Country:US
Practice Address - Phone:941-792-4166
Practice Address - Fax:941-792-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 57421223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty