Healthcare Provider Details

I. General information

NPI: 1821024522
Provider Name (Legal Business Name): KIMBERLY A. DETTORI, D.D.S., M.S., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 SE OCEAN BLVD SUITE 1
STUART FL
34994-2475
US

IV. Provider business mailing address

903 SE OCEAN BLVD SUITE 1
STUART FL
34994-2475
US

V. Phone/Fax

Practice location:
  • Phone: 772-221-3700
  • Fax: 772-221-9107
Mailing address:
  • Phone: 772-221-3700
  • Fax: 772-221-9107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN12143
License Number StateFL

VIII. Authorized Official

Name: DR. KIMBERLY A DETTORI
Title or Position: DENTIST/OWNER
Credential: D.D.S., M.S.
Phone: 772-221-3700