Healthcare Provider Details

I. General information

NPI: 1265600191
Provider Name (Legal Business Name): DYNAMIC DENTAL HEALTH ASSOCIATES OF FLORIDA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 PALM BEACH BLVD
FORT MYERS FL
33905-3270
US

IV. Provider business mailing address

136 4TH ST N STE 201
ST PETERSBURG FL
33701-3889
US

V. Phone/Fax

Practice location:
  • Phone: 239-694-6161
  • Fax: 239-694-0413
Mailing address:
  • Phone: 727-800-8026
  • Fax: 727-304-3164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9392
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number9392
License Number StateFL

VIII. Authorized Official

Name: ROSA LESSO
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 714-571-3471