Provider Demographics
NPI:1952502742
Name:DENTAL EXCELLENCE AT FISHHAWK
Entity Type:Organization
Organization Name:DENTAL EXCELLENCE AT FISHHAWK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KERNAGIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-571-5555
Mailing Address - Street 1:5486 LITHIA PINECREST RD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-2853
Mailing Address - Country:US
Mailing Address - Phone:813-571-5555
Mailing Address - Fax:813-571-5559
Practice Address - Street 1:5486 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-2853
Practice Address - Country:US
Practice Address - Phone:813-571-5555
Practice Address - Fax:813-571-5559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15191122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty