Basic Information
| Provider Information | |||||||||
| NPI: | 1487968467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | JADE | ||||||||
| MiddleName: | ANNIQUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10549 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337330549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278248181 | ||||||||
| FaxNumber: | 7278248166 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 JASMINE WAY | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337564086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278248181 | ||||||||
| FaxNumber: | 7272167040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2010 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 055835 | NY | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 018536400 | 05 | FL | MEDICAID |