Provider Demographics
NPI:1710316336
Name:TRINITY ENDODONTICS
Entity Type:Organization
Organization Name:TRINITY ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRYL
Authorized Official - Middle Name:M
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,MSD
Authorized Official - Phone:863-413-9773
Mailing Address - Street 1:1602 S. FLORIDA AVE, STE #1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803
Mailing Address - Country:US
Mailing Address - Phone:863-413-9773
Mailing Address - Fax:863-688-2960
Practice Address - Street 1:1602 S. FLORIDA AVE, STE #1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803
Practice Address - Country:US
Practice Address - Phone:863-413-9773
Practice Address - Fax:863-688-2960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16500302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization