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General NPI Number Information
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NPI Number | 1306138045
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Entity Type | Organization
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Legal Business Name | MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF WINTER PARK, PA
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Dates
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Enumeration Date | 05/13/2011
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 501 N ORLANDO AVE STE 233
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City | WINTER PARK
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State | FL
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Zip | 32789-2947
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Country | US
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Telephone | 407-622-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 13195 SW 134TH ST FL 2
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City | MIAMI
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State | FL
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Zip | 33186-4461
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Country | US
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Telephone | 305-274-2499
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Fax | 305-274-9312
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Authorized Official
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Title or Position | CREDENTIALING SUPERVISOR
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Name | STEPHANIE GOMEZ
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Credential |
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Telephone | 305-274-2499
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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 | DN5380
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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