Organization
COUNTRYSIDE MALL DENTAL PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ROSTISLAV KRASNOV (OWNER)
(727) 669-1600
Entity
Organization
Contact information
Practice address
27001 US HIGHWAY 19 N STE 1031B, CLEARWATER, FL 33761-3407
(727) 669-1600
Mailing address
27001 US HIGHWAY 19 N STE 1031B, CLEARWATER, FL 33761-3407
(727) 669-1600
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Enumeration date
06/25/2019
Last updated
06/25/2019
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