Healthcare Provider Details

I. General information

NPI: 1508943796
Provider Name (Legal Business Name): THURSTON & ACOSTA DENTAL ASSOCIATES,PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 E PARK ST
AUBURNDALE FL
33823-3411
US

IV. Provider business mailing address

308 E PARK ST
AUBURNDALE FL
33823-3411
US

V. Phone/Fax

Practice location:
  • Phone: 863-967-7548
  • Fax: 863-967-7693
Mailing address:
  • Phone: 863-967-7548
  • Fax: 863-967-7693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8413
License Number StateFL

VIII. Authorized Official

Name: DR. FREDERICK D THURSTON
Title or Position: DR OWNER
Credential: DMD
Phone: 863-967-7548