Healthcare Provider Details

I. General information

NPI: 1760073217
Provider Name (Legal Business Name): LAKE VILLAGE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 S US HIGHWAY 27 # 441E-1
FRUITLAND PARK FL
34731-4497
US

IV. Provider business mailing address

3261 S US HIGHWAY 27 # 441E-1
FRUITLAND PARK FL
34731-4497
US

V. Phone/Fax

Practice location:
  • Phone: 352-314-2729
  • Fax: 352-314-9889
Mailing address:
  • Phone: 352-314-2729
  • Fax: 352-314-9889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. VAMSI KALLEPALLI
Title or Position: DENTIST
Credential: DMD
Phone: 352-314-2729