=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841942489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMAGINE ORTHODONTIC STUDIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2022
-----------------------------------------------------
Last Update Date | 01/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7348 US HIGHWAY 19 N
-----------------------------------------------------
City | PINELLAS PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33781-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-865-5711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11502 N 56TH ST
-----------------------------------------------------
City | TEMPLE TERRACE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33617-2239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-212-1313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MARIELLA CARRENO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-462-4463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------