Healthcare Provider Details

I. General information

NPI: 1699934646
Provider Name (Legal Business Name): COUNTRYSIDE DENTAL ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 S. FLAMINGO RD
COOPER CITY FL
33330-3237
US

IV. Provider business mailing address

5810 S. FLAMINGO RD
COOPER CITY FL
33330-3237
US

V. Phone/Fax

Practice location:
  • Phone: 954-434-3229
  • Fax: 954-680-6254
Mailing address:
  • Phone: 954-434-3229
  • Fax: 954-680-6254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN8648
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN18066
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN18677
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN8648
License Number State

VIII. Authorized Official

Name: DR. MICHAEL J ANCONA
Title or Position: PRESIDENT/DENTIST
Credential: DDS
Phone: 954-434-3229