Provider Demographics
NPI:1265133185
Name:FL SOUTHERN DENTAL PA
Entity type:Organization
Organization Name:FL SOUTHERN DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-596-6011
Mailing Address - Street 1:5830 GRANITE PKWY STE 780
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6775
Mailing Address - Country:US
Mailing Address - Phone:469-596-6011
Mailing Address - Fax:
Practice Address - Street 1:100 WHETSTONE PL STE 308
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5775
Practice Address - Country:US
Practice Address - Phone:904-810-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty