Healthcare Provider Details

I. General information

NPI: 1023738044
Provider Name (Legal Business Name): LITHIA PINECREST SMILES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 S OAKWOOD AVE
BRANDON FL
33511-6124
US

IV. Provider business mailing address

716 S OAKWOOD AVE
BRANDON FL
33511-6124
US

V. Phone/Fax

Practice location:
  • Phone: 813-285-4084
  • Fax: 813-285-4951
Mailing address:
  • Phone: 813-285-4084
  • Fax: 813-285-4951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ANDREW CROUCH
Title or Position: VP
Credential:
Phone: 321-872-8820