| Entity Name: | KIDS SMILES DENTAL, PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 18 Dec 2015 (9 years ago) |
| Last Event: | LC AMENDMENT AND NAME CHANGE |
| Event Date Filed: | 21 Jan 2016 (9 years ago) |
| Document Number: | L15000208251 |
| FEI/EIN Number | 81-1628383 |
| Address: | 1773 WEST FLETCHER AVENUE, TAMPA, FL 33612-1820 |
| Mail Address: | 1773 WEST FLETCHER AVENUE, TAMPA, FL 33612-1820 |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1033661848 | 2016-10-27 | 2018-07-23 | 1773 W FLETCHER AVE, TAMPA, FL, 336121820, US | 1773 W FLETCHER AVE, TAMPA, FL, 33612, US | |||||||||||||||||||||||||||||
|
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| Phone | +1 813-968-2483 |
Authorized person
| Name | MRS. NEELY JORDAN |
| Role | DIRECTOR OF OPERATIONS |
| Phone | 8139682483 |
Taxonomy
| Taxonomy Code | 1223P0221X - Pediatric Dentist |
| License Number | DN13285 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 017306300 |
| State | FL |
| Issuer | MEDICAID |
| Number | 075109000 |
| State | FL |
| Name | Role |
|---|---|
| BLUE WAVE DENTAL GROUP, PLLC | Agent |
| Name | Role | Address |
|---|---|---|
| Sierra, Frank J, Dr. | Manager | 1773 WEST FLETCHER AVENUE, TAMPA, FL 33612-1820 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2018-04-16 | Blue Wave Dental Group PLLC | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2018-04-16 | 1773 W Fletcher Avenue, Tampa, FL 33612 | No data |
| LC AMENDMENT AND NAME CHANGE | 2016-01-21 | KIDS SMILES DENTAL, PLLC | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2016-01-21 | 1773 WEST FLETCHER AVENUE, TAMPA, FL 33612-1820 | No data |
| CHANGE OF MAILING ADDRESS | 2016-01-21 | 1773 WEST FLETCHER AVENUE, TAMPA, FL 33612-1820 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-07-15 |
| ANNUAL REPORT | 2023-01-24 |
| ANNUAL REPORT | 2022-04-05 |
| ANNUAL REPORT | 2021-02-11 |
| ANNUAL REPORT | 2020-06-08 |
| ANNUAL REPORT | 2019-04-25 |
| ANNUAL REPORT | 2018-04-16 |
| ANNUAL REPORT | 2017-03-20 |
| ANNUAL REPORT | 2016-04-28 |
| LC Amendment and Name Change | 2016-01-21 |
Date of last update: 20 Jan 2025
Sources: Florida Department of State
