Healthcare Provider Details

I. General information

NPI: 1497165757
Provider Name (Legal Business Name): GRINS AND GIGGLES PEDIATRIC DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 NW 137TH DR
JONESVILLE FL
32669-2662
US

IV. Provider business mailing address

231 NW 137TH DR
JONESVILLE FL
32669-2662
US

V. Phone/Fax

Practice location:
  • Phone: 352-316-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN17156
License Number StateFL

VIII. Authorized Official

Name: ALISSA DRAGSTEDT
Title or Position: PEDIATRIC DENTIST
Credential:
Phone: 352-316-7400