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General NPI Number Information
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NPI Number | 1174391460
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Entity Type | Organization
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Legal Business Name | BLUE PARK DENTAL PLLC
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Dates
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Enumeration Date | 12/15/2023
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Last Update Date | 12/15/2023
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Provider Practice Location Address
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Address Line | 5470 POST OAK BLVD UNIT 1
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City | WESLEY CHAPEL
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State | FL
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Zip | 33544
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Country | US
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Telephone | 407-455-3486
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Fax |
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Provider Business Mailing Address
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Address Line | 3182 FRESNO PL
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City | ZEPHYRHILLS
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State | FL
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Zip | 33541-2935
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Country | US
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Telephone | 407-455-3486
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | JORDAN BROWN
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Credential | DDS
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Telephone | 407-455-3486
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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