Provider Demographics
NPI:1154700755
Name:NORTH TAMPA DENTAL, P.A.
Entity type:Organization
Organization Name:NORTH TAMPA DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-968-1170
Mailing Address - Street 1:14115 RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-6932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10549 N FLORIDA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6707
Practice Address - Country:US
Practice Address - Phone:813-935-3129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty