Healthcare Provider Details

I. General information

NPI: 1568742351
Provider Name (Legal Business Name): ABSOLUTE DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2314 WEST 23RD STREET
PANAMA CITY FL
32405
US

IV. Provider business mailing address

2314 WEST 23RD STREET
PANAMA CITY FL
32405
US

V. Phone/Fax

Practice location:
  • Phone: 850-784-0818
  • Fax: 850-215-5587
Mailing address:
  • Phone: 850-784-0818
  • Fax: 850-215-5587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN12472
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 8483
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN12472
License Number StateFL

VIII. Authorized Official

Name: MRS. DARLENE COOK
Title or Position: OFFICE MANAGER
Credential:
Phone: 850-784-0818