Healthcare Provider Details

I. General information

NPI: 1538672787
Provider Name (Legal Business Name): BRANDON SMILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 WEST LUMSDEN RD
BRANDON FL
33511
US

IV. Provider business mailing address

926 WEST LUMSDEN RD
BRANDON FL
33511
US

V. Phone/Fax

Practice location:
  • Phone: 813-438-8728
  • Fax: 813-438-8730
Mailing address:
  • Phone: 813-438-8728
  • Fax: 813-438-8730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN16761
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN16761
License Number StateFL

VIII. Authorized Official

Name: DR. ATHANASIOS KOKKAS
Title or Position: MANAGER
Credential: DDS
Phone: 205-999-9527