Provider Demographics
NPI:1295442754
Name:FLORIDA DENTAL PROFESSIONALS, P.A.
Entity type:Organization
Organization Name:FLORIDA DENTAL PROFESSIONALS, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:
Authorized Official - Last Name:THULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8946
Mailing Address - Street 1:11609 S CLEVELAND AVE STE 24
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-2869
Mailing Address - Country:US
Mailing Address - Phone:239-772-3700
Mailing Address - Fax:
Practice Address - Street 1:11609 S CLEVELAND AVE STE 24
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2869
Practice Address - Country:US
Practice Address - Phone:239-772-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA DENTAL PROFESSIONALS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-03
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty