Healthcare Provider Details

I. General information

NPI: 1497282859
Provider Name (Legal Business Name): KELLOGG ENDODONTICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10081 BEACH VERBENA DR
RIVERVIEW FL
33578
US

IV. Provider business mailing address

10081 BEACH VERBENA DR
RIVERVIEW FL
33578-5491
US

V. Phone/Fax

Practice location:
  • Phone: 813-741-1900
  • Fax: 813-741-1901
Mailing address:
  • Phone: 813-741-1900
  • Fax: 813-741-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN20366
License Number StateFL

VIII. Authorized Official

Name: DAVID KELLOGG
Title or Position: PRESIDENT/DENTIST
Credential: DDS, MS
Phone: 813-741-1900