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General NPI Number Information
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NPI Number | 1447976857
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Entity Type | Organization
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Legal Business Name | ESTERO GENERAL DENTISTRY LLC
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Dates
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Enumeration Date | 10/17/2022
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Last Update Date | 10/17/2022
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Provider Practice Location Address
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Address Line | 21301 S TAMIAMI TRL STE 350
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City | ESTERO
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State | FL
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Zip | 33928-2944
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Country | US
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Telephone | 239-948-1990
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Fax |
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Provider Business Mailing Address
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Address Line | 21301 S TAMIAMI TRL STE 350
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City | ESTERO
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State | FL
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Zip | 33928-2944
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Country | US
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Telephone | 239-948-1990
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED MEMBER
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Name | DR. TYLER FREY
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Credential | DMD
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Telephone | 810-845-9695
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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