| Entity Name: | LITHIA PINECREST SMILES PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 10 Jan 2022 (3 years ago) |
| Document Number: | P22000003544 |
| FEI/EIN Number | 87-4505601 |
| Mail Address: | 1475 Belcher Road S, Largo, FL, 33771, US |
| Address: | 716 S OAKWOOD AVE, BRANDON, FL, 33511, US |
| ZIP code: | 33511 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1023738044 | 2022-08-30 | 2022-08-30 | 716 S OAKWOOD AVE, BRANDON, FL, 335116124, US | 716 S OAKWOOD AVE, BRANDON, FL, 335116124, US | |||||||||||||||||||||||
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| Phone | +1 813-285-4084 |
| Fax | 8132854951 |
Authorized person
| Name | ANDREW CROUCH |
| Role | VP |
| Phone | 3218728820 |
Taxonomy
| Taxonomy Code | 122300000X - Dentist |
| Is Primary | Yes |
| Taxonomy Code | 1223E0200X - Endodontist |
| Is Primary | No |
| Taxonomy Code | 1223P0300X - Periodontist |
| Is Primary | No |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| LITHIA PINECREST SMILES PA 401(K) PLAN | 2023 | 874505601 | 2024-05-28 | LITHIA PINECREST SMILES PA | 0 | |||||||||||||||||||||||||||||||
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| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1412 CHAPIN AVENUE, BURLINGAME, CA, 94010 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2024-05-28 |
| Name of individual signing | QIAN LIU |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| CROUCH ANDREW | Agent | 1475 Belcher Road S, Largo, FL, 33771 |
| Name | Role | Address |
|---|---|---|
| CECILIA SORELLE | President | 1475 Belcher Road S, Largo, FL, 33771 |
| Name | Role | Address |
|---|---|---|
| CROUCH ANDREW | Vice President | 1475 Belcher Road S, Largo, FL, 33771 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2024-04-24 | 716 S OAKWOOD AVE, BRANDON, FL 33511 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-04-24 | 1475 Belcher Road S, Largo, FL 33771 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-24 |
| ANNUAL REPORT | 2023-02-21 |
| Domestic Profit | 2022-01-10 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
