Healthcare Provider Details

I. General information

NPI: 1992972442
Provider Name (Legal Business Name): MIDWAY DENTAL CENTER OF FT PIERCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5054 S 25TH ST
FT PIERCE FL
34981
US

IV. Provider business mailing address

5054 S 25TH ST
FT PIERCE FL
34981
US

V. Phone/Fax

Practice location:
  • Phone: 772-464-4822
  • Fax: 772-464-8656
Mailing address:
  • Phone: 772-464-4822
  • Fax: 772-464-8656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberFL006163
License Number StateFL

VIII. Authorized Official

Name: DR. JAMES LOWELL STRAWN
Title or Position: PRESIDENT
Credential: DDS
Phone: 772-464-4822