Provider Demographics
NPI:1568898856
Name:FAMILY DENTAL CENTER
Entity Type:Organization
Organization Name:FAMILY DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:QAYYUM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMBATY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-841-7711
Mailing Address - Street 1:6333 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-6037
Mailing Address - Country:US
Mailing Address - Phone:727-841-7711
Mailing Address - Fax:
Practice Address - Street 1:6333 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-6037
Practice Address - Country:US
Practice Address - Phone:727-841-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10323122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL077757900Medicaid