Healthcare Provider Details

I. General information

NPI: 1609897958
Provider Name (Legal Business Name): DOUGLAS P BETHONEY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DOUGLAS P BETHONEY DMD

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 EICHENFELD DR
BRANDON FL
33511-5908
US

IV. Provider business mailing address

421 ISLEBAY DR
APOLLO BEACH FL
33572-3332
US

V. Phone/Fax

Practice location:
  • Phone: 813-654-3636
  • Fax: 813-651-4984
Mailing address:
  • Phone: 813-654-3636
  • Fax: 813-651-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN15106
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: