Provider Demographics
NPI:1598930646
Name:TUSCAWILLA DENTAL LLC
Entity Type:Organization
Organization Name:TUSCAWILLA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MCCREARY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-423-3652
Mailing Address - Street 1:2102 S RIDGEWOOD AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-4240
Mailing Address - Country:US
Mailing Address - Phone:386-423-3652
Mailing Address - Fax:386-423-3653
Practice Address - Street 1:2102 S RIDGEWOOD AVE
Practice Address - Street 2:STE 6
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-4240
Practice Address - Country:US
Practice Address - Phone:386-423-3652
Practice Address - Fax:386-423-3653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN152071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty