Provider Demographics
NPI:1760695183
Name:FISHHAWK FAMILY DENTAL
Entity Type:Organization
Organization Name:FISHHAWK FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-662-7171
Mailing Address - Street 1:16737 FISHHAWK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-3860
Mailing Address - Country:US
Mailing Address - Phone:813-662-7171
Mailing Address - Fax:813-662-3024
Practice Address - Street 1:16737 FISHHAWK BLVD
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-3860
Practice Address - Country:US
Practice Address - Phone:813-662-7171
Practice Address - Fax:813-662-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN151831223G0001X
FLDN175311223G0001X
FLDN167521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty