Healthcare Provider Details

I. General information

NPI: 1265355788
Provider Name (Legal Business Name): PP SD DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4333 S TAMIAMI TRL STE D
SARASOTA FL
34231-3461
US

IV. Provider business mailing address

6951 SCRUB JAY DR
SARASOTA FL
34241-5223
US

V. Phone/Fax

Practice location:
  • Phone: 941-415-9779
  • Fax: 941-415-9780
Mailing address:
  • Phone: 954-383-8362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. PHENNATDA POLPORNVITOON
Title or Position: OWNER
Credential: DMD
Phone: 954-383-8362