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2787 Sycamore St Ste 106 North Port FL 34289-9513 | |
| (941) 423-1750 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 2787 Sycamore St Ste 106, North Port, Florida |
| Authorized Official Name and Position | Cassandra Petersen (CREDENTIALING TEAM LEAD) |
| Authorized Official Contact | 2175408972 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
2787 Sycamore St Ste 106 North Port FL 34289-9513 Ph: (941) 423-1750 | 2787 Sycamore St Ste 106 North Port FL 34289-9513 Ph: (941) 423-1750 |
| NPI Number | 1972007912 |
|---|---|
| Provider Enumeration Date | 03/23/2018 |
| Last Update Date | 03/23/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972007912 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | (* (Not Available)) | Primary |
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