Provider Demographics
NPI:1427493378
Name:FLORIDA DENTAL, PA
Entity type:Organization
Organization Name:FLORIDA DENTAL, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:CODWISE
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-273-8204
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:866-273-8204
Mailing Address - Fax:866-809-4943
Practice Address - Street 1:4873 HIGHWAY 90 STE A
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32571-1401
Practice Address - Country:US
Practice Address - Phone:850-602-9033
Practice Address - Fax:850-995-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL163151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty