Healthcare Provider Details

I. General information

NPI: 1497278030
Provider Name (Legal Business Name): DR. LAURA ANN KOBERDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 113TH ST
SEMINOLE FL
33772-2800
US

IV. Provider business mailing address

4846 MIRAMAR DR UNIT 1226
MADEIRA BEACH FL
33708-3386
US

V. Phone/Fax

Practice location:
  • Phone: 727-394-6064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN22904
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: