Healthcare Provider Details

I. General information

NPI: 1881161297
Provider Name (Legal Business Name): MAIN STREET CHILDRENS DENTISTRY AND ORTHODONTICS WATERFORD LAKES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12150 LAKE UNDERHILL RD
ORLANDO FL
32825-5012
US

IV. Provider business mailing address

12150 LAKE UNDERHILL RD
ORLANDO FL
32825-5012
US

V. Phone/Fax

Practice location:
  • Phone: 321-319-7027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GOMEZ
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 305-274-2499