Provider Demographics
NPI:1790825289
Name:FAMILY DENTAL GROUP INC
Entity Type:Organization
Organization Name:FAMILY DENTAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-221-0010
Mailing Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6353
Mailing Address - Country:US
Mailing Address - Phone:813-873-9100
Mailing Address - Fax:813-873-9176
Practice Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD STE 120
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6353
Practice Address - Country:US
Practice Address - Phone:813-873-9100
Practice Address - Fax:813-873-9176
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY DENTAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-07
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN49641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL072704100Medicaid