=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508255712
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHSHORE ORTHODONTICS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2015
-----------------------------------------------------
Last Update Date | 01/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13135 KINGS LAKE DR # 103
-----------------------------------------------------
City | GIBSONTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33534-3960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-815-0080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13135 KINGS LAKE DR # 103
-----------------------------------------------------
City | GIBSONTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33534-3960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MATTHEW AHRENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-843-0783
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 18985
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------