=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952518557
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVENTIVE DENTISTRY FOR CHILDREN PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 05/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9713 OVERSEAS HWY
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-3342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-743-4670
-----------------------------------------------------
Fax | 305-743-4899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9713 OVERSEAS HWY
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-3342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-743-4670
-----------------------------------------------------
Fax | 305-743-4899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DENISE MARIE-JEANNE VEDRENNE-RANGEL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 305-743-4670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DN 17035
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------