Healthcare Provider Details

I. General information

NPI: 1639719859
Provider Name (Legal Business Name): CHAIN OF LAKES DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 MAGUIRE ROAD SUITE 159
WINDERMERE FL
34786
US

IV. Provider business mailing address

175 NW 138TH TERRACE SUITE 200
JONESVILLE FL
32669
US

V. Phone/Fax

Practice location:
  • Phone: 407-876-6708
  • Fax: 407-217-5921
Mailing address:
  • Phone: 352-332-3080
  • Fax: 352-333-3729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: VIVEK NERIKAR
Title or Position: DMD- DENTIST OWNER
Credential: DMD
Phone: 904-553-4859