Provider Demographics
NPI:1699934646
Name:COUNTRYSIDE DENTAL ASSOC INC
Entity type:Organization
Organization Name:COUNTRYSIDE DENTAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANCONA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-434-3229
Mailing Address - Street 1:5810 S. FLAMINGO RD
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33330-3237
Mailing Address - Country:US
Mailing Address - Phone:954-434-3229
Mailing Address - Fax:954-680-6254
Practice Address - Street 1:5810 S. FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33330-3237
Practice Address - Country:US
Practice Address - Phone:954-434-3229
Practice Address - Fax:954-680-6254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN8648122300000X
DN8648122300000X
FLDN18677122300000X
FLDN180661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty