Healthcare Provider Details

I. General information

NPI: 1013608884
Provider Name (Legal Business Name): LUMOS DENTAL STUDIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 FUTURE WAY
CELEBRATION FL
34747-4491
US

IV. Provider business mailing address

1701 FUTURE WAY
CELEBRATION FL
34747-4491
US

V. Phone/Fax

Practice location:
  • Phone: 407-497-3817
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RADHA D. PATEL
Title or Position: DENTIST
Credential: DMD
Phone: 407-497-3817