Organization
MAIN STREET CHILDRENS DENTISTRY AND ORTHODONTICS WATERFORD LAKES PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STEPHANIE GOMEZ (CREDENTIALING SUPERVISOR)
(305) 274-2499
Entity
Organization
Contact information
Practice address
12150 LAKE UNDERHILL RD, ORLANDO, FL 32825-5012
(321) 319-7027
Mailing address
12150 LAKE UNDERHILL RD, ORLANDO, FL 32825-5012
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
—
—
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
—
—
Other
Enumeration date
10/24/2018
Last updated
10/24/2018
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