Healthcare Provider Details

I. General information

NPI: 1891465779
Provider Name (Legal Business Name): DENTISTRY OF NORTH PORT PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13801 TAMIAMI TRL STE B
NORTH PORT FL
34287-2017
US

IV. Provider business mailing address

13801 TAMIAMI TRL STE B
NORTH PORT FL
34287-2017
US

V. Phone/Fax

Practice location:
  • Phone: 941-200-5812
  • Fax:
Mailing address:
  • Phone: 941-200-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROSA HERNANDEZ
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 754-610-9880