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General NPI Number Information
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NPI Number | 1013237411
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Entity Type | Organization
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Legal Business Name | DYNAMIC PEDIATRIC DENTISTRY FOR CHILDREN,PLC
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Dates
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Enumeration Date | 06/08/2010
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Last Update Date | 06/08/2010
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Provider Practice Location Address
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Address Line | 3305 SE FEDERAL HWY
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City | STUART
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State | FL
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Zip | 34997-4913
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Country | US
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Telephone | 772-221-3112
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Fax | 772-221-3175
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Provider Business Mailing Address
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Address Line | 3305 SE FEDERAL HWY
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City | STUART
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State | FL
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Zip | 34997-4913
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Country | US
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Telephone | 772-221-3112
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Fax | 772-221-3175
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Authorized Official
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Title or Position | MMGR
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Name | MS. CINDY WILSON
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Credential | DDS
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Telephone | 772-221-3112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN17725
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License Number State | FL
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