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General NPI Number Information
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NPI Number | 1326470436
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Entity Type | Organization
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Legal Business Name | MEDICAID DENTISTRY OF DAYTONA LLC
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Dates
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Enumeration Date | 07/31/2013
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Last Update Date | 05/21/2018
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Provider Practice Location Address
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Address Line | 1021 SOUTH RIDGEWOOD AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32114
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Country | US
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Telephone | 386-304-2677
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Fax | 386-304-1899
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Provider Business Mailing Address
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Address Line | 1021 SOUTH RIDGEWOOD AVE
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City | DAYTONA BEACH
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State | FL
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Zip | 32114
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Country | US
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Telephone | 386-304-2677
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Fax | 386-304-1899
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Authorized Official
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Title or Position | OWNER
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Name | MR. MUBASHIR CHAUDHRY
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Credential | DMD
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Telephone | 386-304-2677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN18742
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN13783
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License Number State | FL
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