=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548989569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUCE TOOTH PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2022
-----------------------------------------------------
Last Update Date | 08/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8500 113TH ST STE B
-----------------------------------------------------
City | SEMINOLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33772-4126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-390-0037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4641 SHORT LEAF LN NE
-----------------------------------------------------
City | SAINT PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33703-3147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-519-7795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. AMY RENEE LUCE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 727-656-7145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------