Provider Demographics
NPI:1013237411
Name:DYNAMIC PEDIATRIC DENTISTRY FOR CHILDREN,PLC
Entity Type:Organization
Organization Name:DYNAMIC PEDIATRIC DENTISTRY FOR CHILDREN,PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MMGR
Authorized Official - Prefix:MS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:772-221-3112
Mailing Address - Street 1:3305 SE FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-4913
Mailing Address - Country:US
Mailing Address - Phone:772-221-3112
Mailing Address - Fax:772-221-3175
Practice Address - Street 1:3305 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-4913
Practice Address - Country:US
Practice Address - Phone:772-221-3112
Practice Address - Fax:772-221-3175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN177251223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076508200Medicaid