=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952113631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROWN DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2025
-----------------------------------------------------
Last Update Date | 01/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3217 VINELAND RD
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34746-4907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-655-4700
-----------------------------------------------------
Fax | 407-279-0740
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3408 W 84TH ST STE 217
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33018-4943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-512-4589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MR. MANUEL GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-512-4589
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------