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General NPI Number Information
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NPI Number | 1780342733
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Entity Type | Organization
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Legal Business Name | FRIENDLY DENTAL PA
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Dates
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Enumeration Date | 12/07/2021
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Last Update Date | 12/13/2021
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Provider Practice Location Address
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Address Line | 23100 VIA VILLAGIO
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City | ESTERO
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State | FL
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Zip | 33928-8301
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Country | US
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Telephone | 239-529-4159
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Fax |
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Provider Business Mailing Address
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Address Line | 16520 S TAMIAMI TRL STE 106
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City | FORT MYERS
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State | FL
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Zip | 33908-5319
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Country | US
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Telephone | 239-529-4159
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ROBIN MAMO
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Credential |
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Telephone | 239-529-4159
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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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