Healthcare Provider Details

I. General information

NPI: 1255025235
Provider Name (Legal Business Name): SAND MINE DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49591 HIGHWAY 27 STE 301
DAVENPORT FL
33897-9507
US

IV. Provider business mailing address

49591 HIGHWAY 27 STE 301
DAVENPORT FL
33897-9507
US

V. Phone/Fax

Practice location:
  • Phone: 6
  • Fax:
Mailing address:
  • Phone: 6
  • 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