Organization
MAIN STREET CHILDRENS DENTISTRY AND ORTHODONTICS OF LAKEWOOD RANCH PLL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STEPHANIE GOMEZ (CREDENTIALING SUPERVISOR)
(305) 274-2499
Entity
Organization
Contact information
Practice address
11649 SR 70 EAST, SUITE 109, BRADENTON, FL 34202
(941) 209-1213
Mailing address
6240 LAKE OSPREY DR DEPT 50226, LAKEWOOD RANCH, FL 34240-8421
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
—
—
Other
Enumeration date
05/01/2018
Last updated
05/01/2018
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