Healthcare Provider Details

I. General information

NPI: 1710028048
Provider Name (Legal Business Name): USCG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10569 LAKE BREEZE DR
SEMINOLE FL
33772-4333
US

IV. Provider business mailing address

10569 LAKE BREEZE DR
SEMINOLE FL
33772-4333
US

V. Phone/Fax

Practice location:
  • Phone: 727-393-7269
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDH19214
License Number StateFL

VIII. Authorized Official

Name: MRS. KAREN LYNN GORDON
Title or Position: DENTAL HYGIENIST
Credential: RDH
Phone: 727-393-7269