Provider Demographics
NPI:1144629031
Name:FAMILY & COSMETIC DENTISTRY
Entity type:Organization
Organization Name:FAMILY & COSMETIC DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:A
Authorized Official - Last Name:VARTDAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-540-2020
Mailing Address - Street 1:331 CAPE CORAL PKWY W
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-5977
Mailing Address - Country:US
Mailing Address - Phone:239-540-2020
Mailing Address - Fax:239-540-8293
Practice Address - Street 1:331 CAPE CORAL PKWY W
Practice Address - Street 2:SUITE A
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-5977
Practice Address - Country:US
Practice Address - Phone:239-540-2020
Practice Address - Fax:239-540-8293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13901122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1366686677OtherNPI
1912089657OtherNPI