=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992078521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDTOWN DENTAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2012
-----------------------------------------------------
Last Update Date | 02/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3011 CENTRAL AVE
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33713-8632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-322-1828
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12197
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33733-2197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | JACQUELINE NELSON-MANGATAL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 786-316-5044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN16582
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------