Healthcare Provider Details

I. General information

NPI: 1710678057
Provider Name (Legal Business Name): DESTINATION DNTL, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10014 US HIGHWAY 301 N
PARRISH FL
34219-8493
US

IV. Provider business mailing address

10014 US HIGHWAY 301 N
PARRISH FL
34219-8493
US

V. Phone/Fax

Practice location:
  • Phone: 941-842-2240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: DR. MICHAEL KUTSYK
Title or Position: PRESIDENT
Credential: DDS
Phone: 941-842-2240