Provider Demographics
NPI:1053606178
Name:PERIODONTAL ASSOCIATES OF TAMPA BAY, P.A.
Entity type:Organization
Organization Name:PERIODONTAL ASSOCIATES OF TAMPA BAY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:VANAELST
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-988-1103
Mailing Address - Street 1:5208 E FOWLER AVE STE F
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2152
Mailing Address - Country:US
Mailing Address - Phone:813-988-1103
Mailing Address - Fax:813-985-1524
Practice Address - Street 1:5208 E FOWLER AVE STE F
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-2152
Practice Address - Country:US
Practice Address - Phone:813-988-1103
Practice Address - Fax:813-985-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN168671223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty