Provider Demographics
NPI:1720597842
Name:CARR PEDIATRIC DENTISTRY, PA
Entity Type:Organization
Organization Name:CARR PEDIATRIC DENTISTRY, PA
Other - Org Name:CARR PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:CARR
Authorized Official - Last Name:BUSTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:813-672-3368
Mailing Address - Street 1:11936 BOYETTE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5601
Mailing Address - Country:US
Mailing Address - Phone:813-672-3368
Mailing Address - Fax:
Practice Address - Street 1:11936 BOYETTE RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5601
Practice Address - Country:US
Practice Address - Phone:813-672-3368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty