Provider Demographics
NPI:1720596067
Name:DENTAL SPECIALTY GROUP OF TAMPA BAY PLLC
Entity Type:Organization
Organization Name:DENTAL SPECIALTY GROUP OF TAMPA BAY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PERIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:FERNANDO
Authorized Official - Last Name:MESIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:352-222-7512
Mailing Address - Street 1:4326 PARK BLVD N STE C-EAST
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-3555
Mailing Address - Country:US
Mailing Address - Phone:727-544-5345
Mailing Address - Fax:727-547-8263
Practice Address - Street 1:4326 PARK BLVD N STE C-EAST
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-3555
Practice Address - Country:US
Practice Address - Phone:727-544-5345
Practice Address - Fax:727-547-8263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty