Provider Demographics
NPI:1629272349
Name:MAIN STREET CHILDREN'S DENTISTRY OF WELLINGTON
Entity Type:Organization
Organization Name:MAIN STREET CHILDREN'S DENTISTRY OF WELLINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:12788 W FOREST HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-4703
Mailing Address - Country:US
Mailing Address - Phone:561-422-2940
Mailing Address - Fax:561-422-2945
Practice Address - Street 1:12788 W FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-4703
Practice Address - Country:US
Practice Address - Phone:561-422-2940
Practice Address - Fax:561-422-2945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty