Provider Demographics
NPI:1811548407
Name:FLORIDA DENTAL PROFESSIONALS, P.A.
Entity Type:Organization
Organization Name:FLORIDA DENTAL PROFESSIONALS, P.A.
Other - Org Name:ESTHETIC & INTEGRATIVE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-6078
Mailing Address - Street 1:390 4TH ST N STE 101
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-2802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:390 4TH ST N STE 101
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-2802
Practice Address - Country:US
Practice Address - Phone:737-282-1980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA DENTAL PROFESSIONALS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-25
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty