Provider Demographics
NPI:1790273159
Name:MAIN STREET CHILDRENS DENTISTRY AND ORTHODONTICS OF LAKEWOOD RANCH PLL
Entity Type:Organization
Organization Name:MAIN STREET CHILDRENS DENTISTRY AND ORTHODONTICS OF LAKEWOOD RANCH PLL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
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 1:6240 LAKE OSPREY DR DEPT 50226
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11649 SR 70 EAST, SUITE 109
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202
Practice Address - Country:US
Practice Address - Phone:941-209-1213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty