Healthcare Provider Details

I. General information

NPI: 1124619556
Provider Name (Legal Business Name): LTC DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 S LAKE DR APT 4
SAINT FRANCIS WI
53235-5256
US

IV. Provider business mailing address

4060 S LAKE DR APT 4
SAINT FRANCIS WI
53235-5256
US

V. Phone/Fax

Practice location:
  • Phone: 407-375-3003
  • Fax: 800-863-5373
Mailing address:
  • Phone: 407-375-3003
  • Fax: 800-863-5373

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: MS. TARA ROBINSON
Title or Position: OWNER
Credential:
Phone: 407-375-3003