Healthcare Provider Details

I. General information

NPI: 1255092987
Provider Name (Legal Business Name): CDPG, P.L.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 SEBASTIAN BLVD STE 180
SEBASTIAN FL
32958-8200
US

IV. Provider business mailing address

1451 SEBASTIAN BLVD STE 180
SEBASTIAN FL
32958-8200
US

V. Phone/Fax

Practice location:
  • Phone: 772-581-8515
  • Fax:
Mailing address:
  • Phone: 772-581-8515
  • 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: CELIA HAYES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100