Provider Demographics
NPI:1861956070
Name:DENTAL ASSOCIATES OF FLORIDA (LUTZ), PLLC
Entity type:Organization
Organization Name:DENTAL ASSOCIATES OF FLORIDA (LUTZ), PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:23641 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-7306
Mailing Address - Country:US
Mailing Address - Phone:813-343-4649
Mailing Address - Fax:
Practice Address - Street 1:23641 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-7306
Practice Address - Country:US
Practice Address - Phone:813-343-4649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental