=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215014337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDEN DENTAL EXCELLENCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7280 STATE ROAD 54
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-376-3763
-----------------------------------------------------
Fax | 727-376-4073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7280 STATE ROAD 54
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-376-3763
-----------------------------------------------------
Fax | 727-376-4073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL COORDINATOR
-----------------------------------------------------
Name | MRS. TRACEY J WILKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-376-3763
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------