Provider Demographics
NPI:1487081352
Name:CHURCHILL PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:CHURCHILL PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J
Authorized Official - Last Name:TARVER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-274-9731
Mailing Address - Street 1:1371 SW 43RD PL
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-7501
Mailing Address - Country:US
Mailing Address - Phone:352-274-9731
Mailing Address - Fax:
Practice Address - Street 1:1371 SW 43RD PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-7501
Practice Address - Country:US
Practice Address - Phone:352-274-9731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-08
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN190381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002880200Medicaid