Provider Demographics
NPI:1588029300
Name:EVERGLADES PEDIATRIC DENTISTRY II
Entity Type:Organization
Organization Name:EVERGLADES PEDIATRIC DENTISTRY II
Other - Org Name:EVERGLADES PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:KINDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:863-382-0340
Mailing Address - Street 1:5606 US HIGHWAY 27 N
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-1211
Mailing Address - Country:US
Mailing Address - Phone:863-382-0340
Mailing Address - Fax:863-357-7342
Practice Address - Street 1:5606 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1211
Practice Address - Country:US
Practice Address - Phone:863-382-0340
Practice Address - Fax:863-357-7342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN166601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1223P0221XMedicaid