Healthcare Provider Details

I. General information

NPI: 1205304375
Provider Name (Legal Business Name): BONITA SPRINGS EDC MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8553 W LINEBAUGH AVE
TAMPA FL
33625-3731
US

IV. Provider business mailing address

PO BOX 788
BOYS TOWN NE
68010-0788
US

V. Phone/Fax

Practice location:
  • Phone: 813-926-9228
  • Fax:
Mailing address:
  • Phone: 402-658-4687
  • Fax: 402-597-3643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL OBENG
Title or Position: MANAGER
Credential:
Phone: 402-981-4136