Provider Demographics
NPI:1134531270
Name:KIDZONE DENTISTRY PA
Entity type:Organization
Organization Name:KIDZONE DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOUNIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:FALEMBAN
Authorized Official - Suffix:
Authorized Official - Credentials:BDS, MDS
Authorized Official - Phone:813-408-4634
Mailing Address - Street 1:6815 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-1543
Mailing Address - Country:US
Mailing Address - Phone:813-408-4634
Mailing Address - Fax:
Practice Address - Street 1:13127 KINGS LAKE DR UNIT 101
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3958
Practice Address - Country:US
Practice Address - Phone:813-677-3047
Practice Address - Fax:813-284-7959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-23
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18289122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007161100Medicaid
FL1144472713OtherNPI