Provider Demographics
NPI:1982619425
Name:MYERS PEDIATRIC DENTISTRY PA
Entity Type:Organization
Organization Name:MYERS PEDIATRIC DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-505-2010
Mailing Address - Street 1:3200 OLD JENNINGS RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-3414
Mailing Address - Country:US
Mailing Address - Phone:904-505-2010
Mailing Address - Fax:904-505-2011
Practice Address - Street 1:3200 OLD JENNINGS RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-3414
Practice Address - Country:US
Practice Address - Phone:904-505-2010
Practice Address - Fax:904-505-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
85410OtherBLUE CROSS BLUE SHIELD
FL1770740OtherUNITED CONCORDIA