Provider Demographics
NPI:1891293387
Name:FLORIDA DENTAL PROFESSIONALS, P.A.
Entity Type:Organization
Organization Name:FLORIDA DENTAL PROFESSIONALS, P.A.
Other - Org Name:COMPLETE DENTAL CARE OF NAPLES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8972
Mailing Address - Street 1:6360 PINE RIDGE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-3907
Mailing Address - Country:US
Mailing Address - Phone:239-354-5353
Mailing Address - Fax:
Practice Address - Street 1:6360 PINE RIDGE RD STE 202
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-3907
Practice Address - Country:US
Practice Address - Phone:239-354-5353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA DENTAL PROFESSIONALS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty