Provider Demographics
NPI:1558842781
Name:DYNAMIC PATHOLOGY PLLC
Entity Type:Organization
Organization Name:DYNAMIC PATHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:941-720-9747
Mailing Address - Street 1:4410 W MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5524
Mailing Address - Country:US
Mailing Address - Phone:941-720-9747
Mailing Address - Fax:866-710-4133
Practice Address - Street 1:4410 W MELROSE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5524
Practice Address - Country:US
Practice Address - Phone:941-720-9747
Practice Address - Fax:866-710-4133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-26
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory