Provider Demographics
NPI:1609471747
Name:FREEDOM DENTAL OF FORT MYERS PA
Entity Type:Organization
Organization Name:FREEDOM DENTAL OF FORT MYERS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:VANDERBOSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-776-9512
Mailing Address - Street 1:14150 METROPOLIS AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14150 METROPOLIS AVE STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4345
Practice Address - Country:US
Practice Address - Phone:239-561-9325
Practice Address - Fax:239-561-8327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-04
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental