| Entity Name: | GULFSHORE PEDIATRIC DENTISTRY, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 14 Apr 2014 (11 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 04 Aug 2015 (10 years ago) |
| Document Number: | P14000033719 |
| FEI/EIN Number | 46-5409759 |
| Address: | 9921 Corkscrew Road, Estero, FL, 33928, US |
| Mail Address: | 9921 CORKSCREW ROAD, ESTERO, FL, 33928, US |
| ZIP code: | 33928 |
| County: | Lee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1982082335 | 2015-05-18 | 2015-05-18 | 9921 CORKSCREW RD, ESTERO, FL, 33928, US | 9921 CORKSCREW RD, ESTERO, FL, 33928, US | |||||||||||||||||||||||||||||||||||
|
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| Phone | +1 239-776-2115 |
Authorized person
| Name | DR. TIA SHEA SAMMONS |
| Role | PEDIATRIC DENTIST |
| Phone | 2397762115 |
Taxonomy
| Taxonomy Code | 1223P0221X - Pediatric Dentist |
| License Number | DN17564 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 1223P0221X - Pediatric Dentist |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 002138100 |
| State | FL |
| Issuer | MEDICAID |
| Number | 076870700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| TARVER EDWARD JIV | Agent | 9921 CORKSCREW ROAD, ESTERO, FL, 33928 |
| Name | Role | Address |
|---|---|---|
| TARVER EDWARD JIV | President | 9921 Corkscrew Rd, Estero, FL, 33928 |
| Name | Role | Address |
|---|---|---|
| TARVER EDWARD JIV | Treasurer | 9921 Corkscrew Rd, Estero, FL, 33928 |
| Name | Role | Address |
|---|---|---|
| TARVER EDWARD JIV | Director | 9921 Corkscrew Rd, Estero, FL, 33928 |
| SAMMONS TIA S | Director | 9921 Corkscrew Rd, Estero, FL, 33928 |
| Name | Role | Address |
|---|---|---|
| SAMMONS TIA S | Vice President | 9921 Corkscrew Rd, Estero, FL, 33928 |
| Name | Role | Address |
|---|---|---|
| SAMMONS TIA S | Secretary | 9921 Corkscrew Rd, Estero, FL, 33928 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDMENT | 2015-08-04 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2015-08-04 | 9921 Corkscrew Road, Estero, FL 33928 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-08-04 | 9921 CORKSCREW ROAD, ESTERO, FL 33928 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2015-03-03 | 9921 Corkscrew Road, Estero, FL 33928 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-04 |
| ANNUAL REPORT | 2023-02-06 |
| ANNUAL REPORT | 2022-03-11 |
| ANNUAL REPORT | 2021-03-03 |
| ANNUAL REPORT | 2020-01-25 |
| ANNUAL REPORT | 2019-04-10 |
| ANNUAL REPORT | 2018-04-23 |
| ANNUAL REPORT | 2017-04-18 |
| ANNUAL REPORT | 2016-04-18 |
| Amendment | 2015-08-04 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
