Healthcare Provider Details

I. General information

NPI: 1700707247
Provider Name (Legal Business Name): CRESTVIEW DENTAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 W JAMES LEE BLVD
CRESTVIEW FL
32536-5166
US

IV. Provider business mailing address

838 W JAMES LEE BLVD
CRESTVIEW FL
32536-5166
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-1858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PETER KELLY
Title or Position: OWNER
Credential:
Phone: 407-432-6224