Healthcare Provider Details

I. General information

NPI: 1841617438
Provider Name (Legal Business Name): A. TINA CHANDRA, D.D.S., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 SW 20TH PL SUITE 202
OCALA FL
34471-7881
US

IV. Provider business mailing address

1920 SW 20TH PL SUITE 202
OCALA FL
34471-7881
US

V. Phone/Fax

Practice location:
  • Phone: 352-861-1500
  • Fax: 352-861-1507
Mailing address:
  • Phone: 352-861-1500
  • Fax: 352-861-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN14503
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: RENEE M CUSTER
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 352-861-1500