Healthcare Provider Details

I. General information

NPI: 1972433084
Provider Name (Legal Business Name): LUMINARY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1178 FAY BLVD
COCOA FL
32927-8739
US

IV. Provider business mailing address

1178 FAY BLVD
COCOA FL
32927-8739
US

V. Phone/Fax

Practice location:
  • Phone: 321-343-3979
  • Fax: 321-220-9697
Mailing address:
  • Phone: 321-343-3979
  • Fax: 321-220-9697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: OWAIS KHAN
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 321-343-3979