Healthcare Provider Details

I. General information

NPI: 1114211273
Provider Name (Legal Business Name): LAKE BALDWIN DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 LAKE BALDWIN LN
ORLANDO FL
32814-6651
US

IV. Provider business mailing address

950 LAKE BALDWIN LN
ORLANDO FL
32814-6651
US

V. Phone/Fax

Practice location:
  • Phone: 407-515-8500
  • Fax: 407-515-3039
Mailing address:
  • Phone: 407-515-8500
  • Fax: 407-515-3039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN16156
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM B DUNN IV
Title or Position: OWNER
Credential: DMD
Phone: 407-515-8500