Provider Demographics
NPI:1710388269
Name:PEDIATRIC AND FAMILY DENTAL GROUP LLC
Entity Type:Organization
Organization Name:PEDIATRIC AND FAMILY DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPEJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-737-7767
Mailing Address - Street 1:PO BOX 590710
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32859-0710
Mailing Address - Country:US
Mailing Address - Phone:407-749-0113
Mailing Address - Fax:407-786-5878
Practice Address - Street 1:6161 WINEGARD RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4977
Practice Address - Country:US
Practice Address - Phone:407-749-0113
Practice Address - Fax:407-786-5878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19618122300000X
FLDN20790122300000X
FLDN182091223P0221X
FLDN171111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty