Provider Demographics
NPI:1245942705
Name:TWO RIVERS FAMILY DENTAL LLC
Entity type:Organization
Organization Name:TWO RIVERS FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBERTO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:786-247-4916
Mailing Address - Street 1:5509 69TH PL E
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-2627
Mailing Address - Country:US
Mailing Address - Phone:786-247-4916
Mailing Address - Fax:
Practice Address - Street 1:515 27TH ST E STE 6
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1879
Practice Address - Country:US
Practice Address - Phone:941-253-0175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental