Provider Demographics
NPI:1891026951
Name:WEISS DENTAL & ORTHODONTICS PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:WEISS DENTAL & ORTHODONTICS PROFESSIONAL CORPORATION
Other - Org Name:COURTESY DENTAL & ORTHODONTICS - CHARLESTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-772-5124
Mailing Address - Street 1:926 GREAT POND DR STE 2003
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:407-772-5124
Mailing Address - Fax:407-788-3572
Practice Address - Street 1:69 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5330
Practice Address - Country:US
Practice Address - Phone:702-453-7200
Practice Address - Fax:702-438-4637
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEISS DENTAL & ORTHODONTICS PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-28
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV45471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty