Provider Demographics
NPI:1376350082
Name:DEEP ROOTS DENTAL AND FACIAL ASETHETICS LLC
Entity type:Organization
Organization Name:DEEP ROOTS DENTAL AND FACIAL ASETHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARNIE
Authorized Official - Middle Name:CHALL
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-839-2273
Mailing Address - Street 1:4509 W CULBREATH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3013 ALLEGRA WAY
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-6997
Practice Address - Country:US
Practice Address - Phone:813-839-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental