Provider Demographics
NPI:1306138045
Name:MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF WINTER PARK, PA
Entity type:Organization
Organization Name:MAIN STREET CHILDREN'S DENTISTRY AND ORTHODONTICS OF WINTER PARK, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:13195 SW 134TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4461
Mailing Address - Country:US
Mailing Address - Phone:305-274-2499
Mailing Address - Fax:305-274-9312
Practice Address - Street 1:501 N ORLANDO AVE STE 233
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2947
Practice Address - Country:US
Practice Address - Phone:407-622-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN5380122300000X
1223X0400X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty