=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538772645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAVARRE CENTER FOR COSMETIC AND FAMILY DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2020
-----------------------------------------------------
Last Update Date | 08/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8158 NAVARRE PKWY
-----------------------------------------------------
City | NAVARRE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32566-6906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-654-8665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4635 GULFSTARR DR STE 200
-----------------------------------------------------
City | DESTIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32541-0742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-654-8665
-----------------------------------------------------
Fax | 850-654-9584
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | VALERIE CALLAHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-654-8665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------