Provider Demographics
NPI:1356724264
Name:TRINITY ENDODONTICS OF GREATER WINTER HAVEN
Entity type:Organization
Organization Name:TRINITY ENDODONTICS OF GREATER WINTER HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRYL
Authorized Official - Middle Name:M
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:863-875-4823
Mailing Address - Street 1:317 CYPRESS GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4452
Mailing Address - Country:US
Mailing Address - Phone:863-875-4823
Mailing Address - Fax:863-875-5564
Practice Address - Street 1:317 CYPRESS GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-875-4823
Practice Address - Fax:863-875-5564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16500302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization