Provider Demographics
NPI:1487741443
Name:DIVITO, KATHLEEN C (DDS)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:C
Last Name:DIVITO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:DIVITO EVERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10710 SEMINOLE BLVD
Mailing Address - Street 2:SUITE #4
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-3316
Mailing Address - Country:US
Mailing Address - Phone:727-392-9293
Mailing Address - Fax:
Practice Address - Street 1:10710 SEMINOLE BLVD
Practice Address - Street 2:SUITE #4
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-3316
Practice Address - Country:US
Practice Address - Phone:727-392-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN86841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice