Provider Demographics
NPI:1770863110
Name:CROWN DENTAL, INC.
Entity Type:Organization
Organization Name:CROWN DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUGO
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR
Authorized Official - Phone:813-873-0271
Mailing Address - Street 1:4812 N HABANA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-6871
Mailing Address - Country:US
Mailing Address - Phone:813-873-0271
Mailing Address - Fax:813-873-2929
Practice Address - Street 1:4812 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6871
Practice Address - Country:US
Practice Address - Phone:813-873-0271
Practice Address - Fax:813-873-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN126391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073641400Medicaid