Provider Demographics
NPI:1932850385
Name:THE TOOTH SHOP ON 46
Entity Type:Organization
Organization Name:THE TOOTH SHOP ON 46
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SYSKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-391-4231
Mailing Address - Street 1:25520 STATE ROAD 46
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:FL
Mailing Address - Zip Code:32776-9526
Mailing Address - Country:US
Mailing Address - Phone:352-735-2211
Mailing Address - Fax:352-735-5844
Practice Address - Street 1:25520 STATE ROAD 46
Practice Address - Street 2:
Practice Address - City:SORRENTO
Practice Address - State:FL
Practice Address - Zip Code:32776-9526
Practice Address - Country:US
Practice Address - Phone:352-735-2211
Practice Address - Fax:352-735-5844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental