Healthcare Provider Details

I. General information

NPI: 1275692154
Provider Name (Legal Business Name): MARINA DENTAL & DENTURE CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CAUSEWAY BLVD SUITE 20
CLEARWATER BEACH FL
33767-2099
US

IV. Provider business mailing address

25 CAUSEWAY BLVD SUITE 20
CLEARWATER BEACH FL
33767-2099
US

V. Phone/Fax

Practice location:
  • Phone: 727-441-8225
  • Fax: 727-441-8225
Mailing address:
  • Phone: 727-441-8225
  • Fax: 727-441-8225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DAVID S PETRIK
Title or Position: PRESIDENT OF CORPORATION
Credential: DDS
Phone: 727-441-8225