Provider Demographics
NPI:1649907809
Name:AQUIDEL DENTAL SERVICES, LLC
Entity type:Organization
Organization Name:AQUIDEL DENTAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING STAFF
Authorized Official - Prefix:
Authorized Official - First Name:MYRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYRENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-596-8123
Mailing Address - Street 1:11574 SW VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11574 SW VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2392
Practice Address - Country:US
Practice Address - Phone:772-204-3113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-06
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty