Provider Demographics
NPI:1548892995
Name:COUNTYLINE DENTISTRY PA
Entity type:Organization
Organization Name:COUNTYLINE DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KEANE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-298-5582
Mailing Address - Street 1:16600 SW 52ND PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST RANCHES
Mailing Address - State:FL
Mailing Address - Zip Code:33331-1340
Mailing Address - Country:US
Mailing Address - Phone:954-298-5582
Mailing Address - Fax:
Practice Address - Street 1:21475 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-3316
Practice Address - Country:US
Practice Address - Phone:305-654-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty