Provider Demographics
NPI:1689118523
Name:FLORIDIAN DENTAL AT PALMETTO BAY, LLC
Entity Type:Organization
Organization Name:FLORIDIAN DENTAL AT PALMETTO BAY, LLC
Other - Org Name:FLORIDIAN DENTAL AT PALMETTO BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HEREDIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-255-4140
Mailing Address - Street 1:15801 S DIXIE HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1837
Mailing Address - Country:US
Mailing Address - Phone:305-255-4140
Mailing Address - Fax:305-252-8323
Practice Address - Street 1:15801 S DIXIE HWY
Practice Address - Street 2:SUITE B
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1837
Practice Address - Country:US
Practice Address - Phone:305-255-4140
Practice Address - Fax:305-252-8323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19253261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental