Healthcare Provider Details

I. General information

NPI: 1568463719
Provider Name (Legal Business Name): GERALD SHELDON COHEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11758 E DR MARTIN LUTHER KING JR BLVD
SEFFNER FL
33584-4923
US

IV. Provider business mailing address

11758 E DR MARTIN LUTHER KING JR BLVD
SEFFNER FL
33584-4923
US

V. Phone/Fax

Practice location:
  • Phone: 813-651-9411
  • Fax:
Mailing address:
  • Phone: 813-651-9411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberFL 10683
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: