Provider Demographics
NPI:1063022051
Name:TD DENTAL GROUP LLC
Entity type:Organization
Organization Name:TD DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANELIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-317-8333
Mailing Address - Street 1:28410 CROSSING BLVD
Mailing Address - Street 2:SUIT 230
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135
Mailing Address - Country:US
Mailing Address - Phone:239-317-8333
Mailing Address - Fax:239-317-8334
Practice Address - Street 1:28410 CROSSING BLVD
Practice Address - Street 2:SUIT 230
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135
Practice Address - Country:US
Practice Address - Phone:239-317-8333
Practice Address - Fax:239-317-8334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental