Healthcare Provider Details

I. General information

NPI: 1891622262
Provider Name (Legal Business Name): NORTH LAKEWOOD DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8528 HERITAGE GREEN WAY
BRADENTON FL
34212-1449
US

IV. Provider business mailing address

3448 CLEVELAND AVE
FORT MYERS FL
33901-7108
US

V. Phone/Fax

Practice location:
  • Phone: 941-941-0205
  • Fax:
Mailing address:
  • Phone: 239-936-3436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TAMMIE STEPHENS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 239-936-3436