Healthcare Provider Details

I. General information

NPI: 1649518069
Provider Name (Legal Business Name): RADIANCE ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 THE RIALTO
VENICE FL
34285-3524
US

IV. Provider business mailing address

730 THE RIALTO
VENICE FL
34285-3524
US

V. Phone/Fax

Practice location:
  • Phone: 941-484-8740
  • Fax:
Mailing address:
  • Phone: 941-484-8740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. SHEILA CHANDRAHASA
Title or Position: MANAGING MEMBER
Credential: DMD
Phone: 941-484-8740