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General NPI Number Information
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NPI Number | 1093539330
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Entity Type | Organization
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Legal Business Name | EDGEWATER FAMILY DENTISTRY PLLC
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Dates
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Enumeration Date | 11/13/2024
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 3512 DEL PRADO BLVD S STE 102
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City | CAPE CORAL
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State | FL
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Zip | 33904-7261
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Country | US
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Telephone | 239-540-1033
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Fax |
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Provider Business Mailing Address
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Address Line | 3512 DEL PRADO BLVD S STE 102
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City | CAPE CORAL
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State | FL
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Zip | 33904-7261
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Country | US
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Telephone | 239-540-1033
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JORDAN TOMALTY
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Credential | DMD
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Telephone | 561-633-9676
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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