Provider Demographics
NPI:1194500827
Name:BAYSHORE PEDIATRIC DENTISTRY AND ORTHODONTICS PLLC
Entity type:Organization
Organization Name:BAYSHORE PEDIATRIC DENTISTRY AND ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-324-1535
Mailing Address - Street 1:11941 WANDSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8002 BEATY GROVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1601
Practice Address - Country:US
Practice Address - Phone:813-324-1535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental