Provider Demographics
NPI:1639622988
Name:CHARLOTTE FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:CHARLOTTE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOURSELAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:941-624-4000
Mailing Address - Street 1:18000 TOLEDO BLADE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-1980
Mailing Address - Country:US
Mailing Address - Phone:941-624-4000
Mailing Address - Fax:941-624-2208
Practice Address - Street 1:18000 TOLEDO BLADE BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1980
Practice Address - Country:US
Practice Address - Phone:941-624-4000
Practice Address - Fax:941-624-2208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN167931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty