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General NPI Number Information
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NPI Number | 1740326321
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Entity Type | Organization
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Legal Business Name | FLORIDA AVENUE DENTISTRY, P.A.
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 09/12/2017
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Provider Practice Location Address
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Address Line | 1212 N FLORIDA AVENUE
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City | LAKELAND
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State | FL
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Zip | 33805
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Country | US
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Telephone | 863-686-2268
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Fax | 863-603-0688
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Provider Business Mailing Address
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Address Line | PO BOX 91966
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City | LAKELAND
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State | FL
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Zip | 33804-1966
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Country | US
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Telephone | 863-686-2268
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Fax | 863-603-0688
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOE N PINKSTON
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Credential | D.D.S.
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Telephone | 863-686-2268
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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 | 12541
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License Number State | FL
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