Provider Demographics
NPI:1891128773
Name:PEDIATRIC DENTISTRY OF NEW TAMPA
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF NEW TAMPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:MILAGROS
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-374-0388
Mailing Address - Street 1:5326 PRIMROSE LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3589
Mailing Address - Country:US
Mailing Address - Phone:813-374-0388
Mailing Address - Fax:813-374-0390
Practice Address - Street 1:5326 PRIMROSE LAKE CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3589
Practice Address - Country:US
Practice Address - Phone:813-374-0388
Practice Address - Fax:813-374-0390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN144831223P0221X
FLDN195201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty