Provider Demographics
NPI:1841942489
Name:IMAGINE ORTHODONTIC STUDIO
Entity type:Organization
Organization Name:IMAGINE ORTHODONTIC STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-462-4463
Mailing Address - Street 1:11502 N 56TH ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2239
Mailing Address - Country:US
Mailing Address - Phone:813-212-1313
Mailing Address - Fax:
Practice Address - Street 1:7348 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-4600
Practice Address - Country:US
Practice Address - Phone:727-865-5711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:000000
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty