Provider Demographics
NPI:1043861776
Name:YOUR DENTAL LLC
Entity type:Organization
Organization Name:YOUR DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WIDMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:239-262-2677
Mailing Address - Street 1:4959 CASTELLO DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-8927
Mailing Address - Country:US
Mailing Address - Phone:239-262-2677
Mailing Address - Fax:239-261-2670
Practice Address - Street 1:4959 CASTELLO DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-8927
Practice Address - Country:US
Practice Address - Phone:239-262-2677
Practice Address - Fax:239-261-2670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental