Provider Demographics
NPI:1710244702
Name:PEDIATRIC DENTAL CENTER
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-685-0804
Mailing Address - Street 1:517 CORNER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5718
Mailing Address - Country:US
Mailing Address - Phone:813-685-0804
Mailing Address - Fax:813-681-7213
Practice Address - Street 1:517 CORNER DRIVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5718
Practice Address - Country:US
Practice Address - Phone:813-685-0804
Practice Address - Fax:813-681-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN63771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074133700Medicaid