=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295501336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARINA POINTE DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2023
-----------------------------------------------------
Last Update Date | 11/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2407 W 11TH ST
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32401-1634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-451-0701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43 SPOONBILL RD
-----------------------------------------------------
City | SANTA ROSA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32459-6857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-451-0701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ALEJANDRO ANDRES NIEVES MONTALVO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 786-451-0701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------