Provider Demographics
NPI:1588088223
Name:DENTAL ASSOC OF SOUTH BRANDON
Entity type:Organization
Organization Name:DENTAL ASSOC OF SOUTH BRANDON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:B
Authorized Official - Last Name:BARRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-684-6279
Mailing Address - Street 1:611 E BLOOMINGDALE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8127
Mailing Address - Country:US
Mailing Address - Phone:813-684-6279
Mailing Address - Fax:813-684-2189
Practice Address - Street 1:611 E BLOOMINGDALE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8127
Practice Address - Country:US
Practice Address - Phone:813-684-6279
Practice Address - Fax:813-684-2189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty