Provider Demographics
NPI:1760120166
Name:FLORIDA DENTAL PROFESSIONALS, P.A.
Entity Type:Organization
Organization Name:FLORIDA DENTAL PROFESSIONALS, P.A.
Other - Org Name:SOMERSET DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8306
Mailing Address - Street 1:15277 AMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15277 AMBERLY DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2155
Practice Address - Country:US
Practice Address - Phone:813-971-1688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA DENTAL PROFESSIONALS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-25
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty