Healthcare Provider Details

I. General information

NPI: 1851051536
Provider Name (Legal Business Name): LARGO DENTAL ONE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 BELCHER RD S
LARGO FL
33771-5243
US

IV. Provider business mailing address

1475 BELCHER RD S
LARGO FL
33771-5243
US

V. Phone/Fax

Practice location:
  • Phone: 727-287-1555
  • Fax: 727-290-0589
Mailing address:
  • Phone: 727-287-1555
  • Fax: 727-290-0589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: ANDREW CROUCH
Title or Position: VP
Credential:
Phone: 321-872-8820