Healthcare Provider Details

I. General information

NPI: 1467894980
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF BRANDON PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 CORNER DR
BRANDON FL
33511-5718
US

IV. Provider business mailing address

517 CORNER DR
BRANDON FL
33511-5718
US

V. Phone/Fax

Practice location:
  • Phone: 787-398-7143
  • Fax: 813-681-7213
Mailing address:
  • Phone: 787-398-7143
  • Fax: 813-681-7213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. KERRY J TORRES
Title or Position: PRACTICE MANAGER
Credential:
Phone: 787-398-7143