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General NPI Number Information
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NPI Number | 1588088223
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Entity Type | Organization
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Legal Business Name | DENTAL ASSOC OF SOUTH BRANDON
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Dates
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Enumeration Date | 02/18/2014
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Last Update Date | 02/18/2014
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Provider Practice Location Address
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Address Line | 611 E BLOOMINGDALE AVE SUITE C
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City | BRANDON
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State | FL
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Zip | 33511-8127
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Country | US
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Telephone | 813-684-6279
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Fax | 813-684-2189
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Provider Business Mailing Address
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Address Line | 611 E BLOOMINGDALE AVE SUITE C
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City | BRANDON
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State | FL
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Zip | 33511-8127
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Country | US
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Telephone | 813-684-6279
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Fax | 813-684-2189
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Authorized Official
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Title or Position | INSURANCE SUPERVISOR
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Name | MRS. CRYSTAL B BARRON
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Credential |
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Telephone | 813-684-6279
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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 |
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License Number State |
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