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General NPI Number Information
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NPI Number | 1457360075
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Entity Type | Organization
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Legal Business Name | PORT CHARLOTTE DENTAL CARE INC
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3441 CONWAY BLVD
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-7002
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Country | US
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Telephone | 941-764-9555
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Fax | 941-764-9277
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Provider Business Mailing Address
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Address Line | 3441 CONWAY BLVD
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-7002
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Country | US
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Telephone | 941-764-9555
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Fax | 941-764-9277
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Authorized Official
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Title or Position | CEO
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Name | JOSEPH HALIM FARAG
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Credential | DMD
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Telephone | 941-764-9555
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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 | DN16330
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License Number State | FL
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