Provider Demographics
NPI:1063620789
Name:COUNTYLINE DENTAL, LLP
Entity type:Organization
Organization Name:COUNTYLINE DENTAL, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:PASISNITCHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-654-1234
Mailing Address - Street 1:21457 NW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-2120
Mailing Address - Country:US
Mailing Address - Phone:305-654-1234
Mailing Address - Fax:484-348-0322
Practice Address - Street 1:21457 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-2120
Practice Address - Country:US
Practice Address - Phone:305-654-1234
Practice Address - Fax:484-348-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN154701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty