Provider Demographics
NPI:1760687149
Name:MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF WELLINGTON, PA
Entity Type:Organization
Organization Name:MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF WELLINGTON, PA
Other - Org Name:
Other - Org Type:
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:561-422-2945
Practice Address - Street 1:11903 SOUTHERN BLVD.
Practice Address - Street 2:SUITE #102
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411
Practice Address - Country:US
Practice Address - Phone:561-422-2940
Practice Address - Fax:561-422-2945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty