Provider Demographics
NPI:1578170684
Name:PARK BOULEVARD FAMILY DENTISTRY
Entity Type:Organization
Organization Name:PARK BOULEVARD FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIANNE
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-244-6045
Mailing Address - Street 1:4326 PARK BLVD N STE A
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-3538
Mailing Address - Country:US
Mailing Address - Phone:727-291-0220
Mailing Address - Fax:
Practice Address - Street 1:4326 PARK BLVD N STE A
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-3538
Practice Address - Country:US
Practice Address - Phone:727-291-0220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty