Provider Demographics
NPI:1811107485
Name:JAY R. FROUG, D.M.D., P.A. D/B/A PINEBROOK DENTAL CENTER
Entity type:Organization
Organization Name:JAY R. FROUG, D.M.D., P.A. D/B/A PINEBROOK DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:FROUG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:941-795-0877
Mailing Address - Street 1:4868 CORTEZ RD W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-2803
Mailing Address - Country:US
Mailing Address - Phone:941-795-0877
Mailing Address - Fax:941-795-5316
Practice Address - Street 1:4868 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-2803
Practice Address - Country:US
Practice Address - Phone:941-795-0877
Practice Address - Fax:941-795-5316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00104941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL59129772OtherBCBS OF AL
67366OtherBCBS
PA410947OtherUNITED CONCORDIA
MAZP9540OtherBCBS OF MA