Provider Demographics
NPI:1124122569
Name:COMPLETE DENTAL CARE PA
Entity type:Organization
Organization Name:COMPLETE DENTAL CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:HANNAH-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-977-4819
Mailing Address - Street 1:11213 N NEBRASKA AVE
Mailing Address - Street 2:SUITE 406C
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5775
Mailing Address - Country:US
Mailing Address - Phone:813-977-4819
Mailing Address - Fax:813-977-4568
Practice Address - Street 1:11213 N NEBRASKA AVE
Practice Address - Street 2:SUITE 406C
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5775
Practice Address - Country:US
Practice Address - Phone:813-977-4819
Practice Address - Fax:813-977-4568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0012708122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073523001Medicaid