Healthcare Provider Details

I. General information

NPI: 1598724296
Provider Name (Legal Business Name): KATHLEEN M. DU LAC DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W LAKE MARY BLVD
LAKE MARY FL
32746-3501
US

IV. Provider business mailing address

446 N PINE MEADOW DR
DEBARY FL
32713-2305
US

V. Phone/Fax

Practice location:
  • Phone: 407-328-6411
  • Fax:
Mailing address:
  • Phone: 407-340-4922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN17088
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: