Provider Demographics
NPI:1841625910
Name:MIDPOINT DENTISTRY
Entity type:Organization
Organization Name:MIDPOINT DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:P
Authorized Official - Last Name:FAVALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-418-1444
Mailing Address - Street 1:7117 CONGDON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4216
Mailing Address - Country:US
Mailing Address - Phone:239-418-1444
Mailing Address - Fax:239-418-1888
Practice Address - Street 1:7117 CONGDON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4216
Practice Address - Country:US
Practice Address - Phone:239-418-1444
Practice Address - Fax:239-418-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN137381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070912300Medicaid