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General NPI Number Information
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NPI Number | 1033373022
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Entity Type | Organization
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Legal Business Name | PARK AVENUE DENTAL
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Dates
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Enumeration Date | 07/18/2008
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Last Update Date | 07/18/2008
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Provider Practice Location Address
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Address Line | 912 NW 56TH TER STE B
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City | GAINESVILLE
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State | FL
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Zip | 32605-6404
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Country | US
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Telephone | 352-331-7573
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Fax |
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Provider Business Mailing Address
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Address Line | 912 NW 56TH TER STE B
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City | GAINESVILLE
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State | FL
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Zip | 32605-6404
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Country | US
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Telephone | 352-331-7573
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. SHANE NELIS GOSLINGA
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Credential | DMD
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Telephone | 352-331-7573
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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 | 17071
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License Number State | FL
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