Provider Demographics
NPI:1811099062
Name:POTEMPA, PHIL (DDS)
Entity type:Individual
Prefix:DR
First Name:PHIL
Middle Name:
Last Name:POTEMPA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LOVELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33980
Mailing Address - Country:US
Mailing Address - Phone:941-624-7200
Mailing Address - Fax:941-624-7274
Practice Address - Street 1:1100 LOVELAND BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980
Practice Address - Country:US
Practice Address - Phone:941-624-7200
Practice Address - Fax:941-624-7274
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN174741223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02792420411Medicaid
FL076162100Medicaid
FLP351679422910OtherDR LICENSE