Provider Demographics
NPI:1760619860
Name:MAIN STREET CHILDREN'S DENTISTRY & ORTHODONTICS OF NAPLES, PA
Entity Type:Organization
Organization Name:MAIN STREET CHILDREN'S DENTISTRY & ORTHODONTICS OF NAPLES, PA
Other - Org Name:MAIN STREET CHILDREN'S DENTISTRY OF NAPLES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:13195 SW 134 ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186
Mailing Address - Country:US
Mailing Address - Phone:305-274-2499
Mailing Address - Fax:239-254-0059
Practice Address - Street 1:6726 LONE OAK BLVD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109
Practice Address - Country:US
Practice Address - Phone:239-254-0085
Practice Address - Fax:239-254-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 5380122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty