Provider Demographics
NPI:1740326321
Name:FLORIDA AVENUE DENTISTRY, P.A.
Entity type:Organization
Organization Name:FLORIDA AVENUE DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:N
Authorized Official - Last Name:PINKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:863-686-2268
Mailing Address - Street 1:PO BOX 91966
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804-1966
Mailing Address - Country:US
Mailing Address - Phone:863-686-2268
Mailing Address - Fax:863-603-0688
Practice Address - Street 1:1212 N FLORIDA AVENUE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-686-2268
Practice Address - Fax:863-603-0688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL125411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty