Healthcare Provider Details

I. General information

NPI: 1962794602
Provider Name (Legal Business Name): MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF FT. MYERS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13195 METRO PKWY
FORT MYERS FL
33966-4810
US

IV. Provider business mailing address

13195 SW 134TH ST FL 2
MIAMI FL
33186-4461
US

V. Phone/Fax

Practice location:
  • Phone: 239-768-2485
  • Fax:
Mailing address:
  • Phone: 305-274-2499
  • Fax: 305-274-9312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GOMEZ
Title or Position: PROVIDER RELATIONS SPECIALIST
Credential:
Phone: 305-274-2499