Provider Demographics
NPI:1023584174
Name:DENTAL OFFICE OF PALM HARBOR INC
Entity type:Organization
Organization Name:DENTAL OFFICE OF PALM HARBOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINSTRATION
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-738-8845
Mailing Address - Street 1:3438 TAMPA RD STE 11
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3530
Mailing Address - Country:US
Mailing Address - Phone:727-786-1077
Mailing Address - Fax:727-781-2131
Practice Address - Street 1:3438 TAMPA RD STE 11
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3530
Practice Address - Country:US
Practice Address - Phone:727-786-1077
Practice Address - Fax:727-781-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherGENERAL DENTIST