Healthcare Provider Details

I. General information

NPI: 1992086771
Provider Name (Legal Business Name): MARY TERESA GUNNING PRENDIVILLE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 E MAIN ST
BARTOW FL
33830-5202
US

IV. Provider business mailing address

1407 PLANTATION CIR APT 305
PLANT CITY FL
33566-1508
US

V. Phone/Fax

Practice location:
  • Phone: 863-533-0324
  • Fax:
Mailing address:
  • Phone: 305-972-4887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN20902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: