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General NPI Number Information
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NPI Number | 1922529916
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Entity Type | Organization
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Legal Business Name | FOREST PARK DENTAL PLLC
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Dates
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Enumeration Date | 06/29/2017
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Last Update Date | 06/29/2017
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Provider Practice Location Address
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Address Line | 2620 JENKS AVE
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City | PANAMA CITY
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State | FL
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Zip | 32405-4311
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Country | US
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Telephone | 850-785-8586
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Fax |
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Provider Business Mailing Address
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Address Line | 3150 ZELDA CT
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City | MONTGOMERY
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State | AL
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Zip | 36106-2607
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Country | US
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Telephone | 334-676-2320
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | SUSAN STEWART
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Credential |
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Telephone | 334-676-2320
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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 |
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License Number State |
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