Provider Demographics
NPI:1538238589
Name:COUNRTYSIDE DENTAL
Entity type:Organization
Organization Name:COUNRTYSIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-669-2887
Mailing Address - Street 1:2165 PALMETTO STREET
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765
Mailing Address - Country:US
Mailing Address - Phone:727-669-2887
Mailing Address - Fax:727-669-9103
Practice Address - Street 1:2165 PALMETTO STREET
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765
Practice Address - Country:US
Practice Address - Phone:727-669-2887
Practice Address - Fax:727-669-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty