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General NPI Number Information
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NPI Number | 1639622988
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Entity Type | Organization
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Legal Business Name | CHARLOTTE FAMILY DENTISTRY LLC
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Dates
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Enumeration Date | 08/03/2016
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Last Update Date | 08/03/2016
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Provider Practice Location Address
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Address Line | 18000 TOLEDO BLADE BLVD
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City | PORT CHARLOTTE
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State | FL
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Zip | 33948-1980
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Country | US
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Telephone | 941-624-4000
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Fax | 941-624-2208
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Provider Business Mailing Address
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Address Line | 18000 TOLEDO BLADE BLVD
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City | PORT CHARLOTTE
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State | FL
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Zip | 33948-1980
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Country | US
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Telephone | 941-624-4000
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Fax | 941-624-2208
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. DEAN J MOURSELAS
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Credential | DDS
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Telephone | 941-624-4000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN16793
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License Number State | FL
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