Healthcare Provider Details

I. General information

NPI: 1063768372
Provider Name (Legal Business Name): ALTAMONTE MALL DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 E ALTAMONTE DR STE 1279
ALTAMONTE SPRINGS FL
32701-4617
US

IV. Provider business mailing address

451 E ALTAMONTE DR STE 1279
ALTAMONTE SPRINGS FL
32701-4617
US

V. Phone/Fax

Practice location:
  • Phone: 954-846-7171
  • Fax: 954-846-7170
Mailing address:
  • Phone: 954-846-7171
  • Fax: 954-846-7170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN16377
License Number StateFL

VIII. Authorized Official

Name: DR. ROSTISLAV KRASNOV
Title or Position: OWNER
Credential: DDS
Phone: 954-846-7171