Provider Demographics
NPI:1750068482
Name:GREAT FLORIDA SMILES & ORTHODONTICS PCB, PLLC
Entity type:Organization
Organization Name:GREAT FLORIDA SMILES & ORTHODONTICS PCB, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-622-5888
Mailing Address - Street 1:755 GRAND BLVD STE 105B285
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-1838
Mailing Address - Country:US
Mailing Address - Phone:850-622-5888
Mailing Address - Fax:
Practice Address - Street 1:900 THOMAS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32408-7442
Practice Address - Country:US
Practice Address - Phone:850-249-9311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty