Healthcare Provider Details

I. General information

NPI: 1336748946
Provider Name (Legal Business Name): TRAE PAPPAS DDS P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5170 S FERDON BLVD
CRESTVIEW FL
32536-9258
US

IV. Provider business mailing address

5170 S FERDON BLVD
CRESTVIEW FL
32536-9258
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-2332
  • Fax:
Mailing address:
  • Phone: 850-689-2332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TRAE HARBESON PAPPAS
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 850-685-8461