Healthcare Provider Details

I. General information

NPI: 1659677714
Provider Name (Legal Business Name): MJ DENTAL SERVICES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 WEST OLD HIGHWAY 441
MOUNT DORA FL
32757-3508
US

IV. Provider business mailing address

2230 WEST OLD HIGHWAY 441
MOUNT DORA FL
32757-3508
US

V. Phone/Fax

Practice location:
  • Phone: 352-383-2959
  • Fax: 352-735-3355
Mailing address:
  • Phone: 352-383-2959
  • Fax: 352-735-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN18726
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN6360
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH5118
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH15460
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH5702
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number106953
License Number StateFL

VIII. Authorized Official

Name: DR. MITESH JIVAN
Title or Position: PRESIDENT
Credential: DMD
Phone: 352-383-2959