Healthcare Provider Details

I. General information

NPI: 1699861336
Provider Name (Legal Business Name): INDIGO DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 EXECUTIVE CIR SUITE 101
DAYTONA BEACH FL
32114-1198
US

IV. Provider business mailing address

139 EXECUTIVE CIR SUITE 101
DAYTONA BEACH FL
32114-1198
US

V. Phone/Fax

Practice location:
  • Phone: 386-253-3629
  • Fax: 386-253-3620
Mailing address:
  • Phone: 386-253-3629
  • Fax: 386-253-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN0013454
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID ROBERT LLOYD
Title or Position: PRESIDENT
Credential: DDS
Phone: 386-253-3629