Healthcare Provider Details

I. General information

NPI: 1427942143
Provider Name (Legal Business Name): MOUNT DORA FAMILY DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18660 HIGHWAY 441 SUITE 106
MOUNT DORA FL
32757
US

IV. Provider business mailing address

18660 HIGHWAY 441 SUITE 106
MOUNT DORA FL
32757
US

V. Phone/Fax

Practice location:
  • Phone: 352-755-1020
  • Fax:
Mailing address:
  • Phone: 352-755-1020
  • Fax: 407-574-4651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PETER KELLY
Title or Position: OWNER
Credential:
Phone: 407-432-6224