Provider Demographics
NPI:1538436522
Name:EVERGLADES PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:EVERGLADES PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KINDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:863-467-2332
Mailing Address - Street 1:2029 HIGHWAY 441 NORTH
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34972
Mailing Address - Country:US
Mailing Address - Phone:863-467-2332
Mailing Address - Fax:863-467-2347
Practice Address - Street 1:2029 HIGHWAY 441 NORTH
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972
Practice Address - Country:US
Practice Address - Phone:863-467-2332
Practice Address - Fax:863-467-2347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN166601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty