# COUNTRYSIDE DENTAL ASSOC INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1699934646
- **Authorized official:** DR. MICHAEL J ANCONA DDS (PRESIDENT/DENTIST)
- **Authorized official phone:** (954) 434-3229

## Contact information

- **Practice address:** 5810 S. FLAMINGO RD, COOPER CITY, FL 33330-3237
- **Practice address phone:** (954) 434-3229
- **Practice address fax:** (954) 680-6254
- **Mailing address:** 5810 S. FLAMINGO RD, COOPER CITY, FL 33330-3237
- **Mailing address phone:** (954) 434-3229
- **Mailing address fax:** (954) 680-6254

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | DN18677 | FL | — |
| 122300000X | Dentist | DN8648 | FL | — |
| 122300000X | Dentist | DN8648 | — | Yes |
| 1223G0001X | General Practice Dentistry | DN18066 | FL | — |

## Other

- **Enumeration date:** 06/05/2008
- **Last updated:** 01/20/2011