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General NPI Number Information
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NPI Number | 1154643377
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Entity Type | Organization
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Legal Business Name | INTERNATIONAL CENTER FOR COMPLETE DENTISTRY
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Dates
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Enumeration Date | 02/16/2010
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Last Update Date | 06/23/2010
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Provider Practice Location Address
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Address Line | 111 2ND AVE NE #1104
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City | SAINT PETERSBURG
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State | FL
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Zip | 33701-3434
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Country | US
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Telephone | 727-821-4433
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Fax | 727-822-7252
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Provider Business Mailing Address
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Address Line | 111 2ND AVE NE #1104
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City | SAINT PETERSBURG
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State | FL
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Zip | 33701-3434
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Country | US
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Telephone | 727-821-4433
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Fax | 727-822-7252
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Authorized Official
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Title or Position | RN, OFFICE MANAGER
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Name | MRS. DREAMA MICHELLE WEGZYN
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Credential |
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Telephone | 727-821-4433
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | DN4596
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License Number State | FL
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