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General NPI Number Information
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NPI Number | 1023171584
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Entity Type | Organization
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Legal Business Name | HAVENDALE DENTAL OFF PA
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7111 CYPRESS GARDEN BLVD
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City | WINTER HAVEN
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State | FL
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Zip | 33884
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Country | US
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Telephone | 863-324-7401
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Fax | 863-324-1024
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Provider Business Mailing Address
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Address Line | 7111 CYPRESS GARDEN BLVD
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City | WINTER HAVEN
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State | FL
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Zip | 33884
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Country | US
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Telephone | 863-324-7401
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Fax | 863-324-1024
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Authorized Official
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Title or Position | PRESIDENT
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Name | DIPAK VRAJLAL SHETH
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Credential |
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Telephone | 863-324-7401
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 52172
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN10392
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License Number State | FL
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