Healthcare Provider Details

I. General information

NPI: 1134524424
Provider Name (Legal Business Name): MEADOWS ADULT DENTAL SERVICES SR 64 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9916 E STATE ROAD 64
BRADENTON FL
34212-5303
US

IV. Provider business mailing address

9916 E STATE ROAD 64
BRADENTON FL
34212-5303
US

V. Phone/Fax

Practice location:
  • Phone: 941-745-1143
  • Fax: 941-708-0555
Mailing address:
  • Phone: 941-745-1143
  • Fax: 941-708-0555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. GEORGE J MEADOWS JR.
Title or Position: MANAGING MEMBER
Credential: DMD
Phone: 941-745-1143