Healthcare Provider Details

I. General information

NPI: 1093469827
Provider Name (Legal Business Name): TOOTH FAIRY DENTAL II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10205 S DIXIE HWY STE 200-201
PINECREST FL
33156-3167
US

IV. Provider business mailing address

10205 S DIXIE HWY STE 200-201
PINECREST FL
33156-3167
US

V. Phone/Fax

Practice location:
  • Phone: 561-891-9046
  • Fax:
Mailing address:
  • Phone: 561-891-9046
  • 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: SCOTT SPENCER
Title or Position: OWNER
Credential: DOCTOR
Phone: 561-891-9046