Healthcare Provider Details

I. General information

NPI: 1245991017
Provider Name (Legal Business Name): CDPG, P.L.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 E MERRITT ISLAND CSWY STE 220
MERRITT ISLAND FL
32952-3311
US

IV. Provider business mailing address

775 E MERRITT ISLAND CSWY STE 220
MERRITT ISLAND FL
32952-3311
US

V. Phone/Fax

Practice location:
  • Phone: 321-453-0696
  • Fax:
Mailing address:
  • Phone: 321-453-0696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CELIA HAYES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100