Provider Demographics
NPI:1528301058
Name:ARTISTIC DENTAL OF POLK CITY, LLC
Entity type:Organization
Organization Name:ARTISTIC DENTAL OF POLK CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:GOLDSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:863-984-0000
Mailing Address - Street 1:120 CARTER BLVD STE 7
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33868-8912
Mailing Address - Country:US
Mailing Address - Phone:863-984-0000
Mailing Address - Fax:
Practice Address - Street 1:120 CARTER BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:POLK CITY
Practice Address - State:FL
Practice Address - Zip Code:33868-8908
Practice Address - Country:US
Practice Address - Phone:863-984-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN4587261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental