Provider Demographics
NPI:1952745408
Name:GENTLE BREEZE DENTAL
Entity Type:Organization
Organization Name:GENTLE BREEZE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:TRONG
Authorized Official - Last Name:DIEP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-474-1549
Mailing Address - Street 1:1761 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5479
Mailing Address - Country:US
Mailing Address - Phone:321-474-1549
Mailing Address - Fax:
Practice Address - Street 1:1761 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5479
Practice Address - Country:US
Practice Address - Phone:321-474-1549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty