Provider Demographics
NPI:1982082335
Name:GULFSHORE PEDIATRIC DENTISTRY, P.A.
Entity type:Organization
Organization Name:GULFSHORE PEDIATRIC DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIA
Authorized Official - Middle Name:SHEA
Authorized Official - Last Name:SAMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-776-2115
Mailing Address - Street 1:9921 CORKSCREW RD
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928
Mailing Address - Country:US
Mailing Address - Phone:239-776-2115
Mailing Address - Fax:
Practice Address - Street 1:9921 CORKSCREW RD
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928
Practice Address - Country:US
Practice Address - Phone:239-776-2115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN175641223P0221X
FL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002138100Medicaid
FL076870700Medicaid