Healthcare Provider Details

I. General information

NPI: 1033560586
Provider Name (Legal Business Name): CHARLES D. LLANO, D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 WEST HIGHLAND DRIVE
LAKELAND FL
33813
US

IV. Provider business mailing address

320 WEST HIGHLAND DRIVE
LAKELAND FL
33813
US

V. Phone/Fax

Practice location:
  • Phone: 863-644-2428
  • Fax: 863-644-6235
Mailing address:
  • Phone: 863-644-2428
  • Fax: 863-644-6235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6425
License Number StateFL

VIII. Authorized Official

Name: MRS. KRIS HOWARD
Title or Position: OFFICE MANAGER
Credential:
Phone: 863-644-2428