Provider Demographics
NPI:1194157222
Name:KIDZ CHOICE PEDIATRIC DENTISTRY OF CENTRAL FLORIDA
Entity type:Organization
Organization Name:KIDZ CHOICE PEDIATRIC DENTISTRY OF CENTRAL FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERESIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-422-2617
Mailing Address - Street 1:508 N MILLS AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 N MILLS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5353
Practice Address - Country:US
Practice Address - Phone:407-422-2617
Practice Address - Fax:407-841-6843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18945261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008810400Medicaid