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General NPI Number Information
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NPI Number | 1407330145
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Entity Type | Organization
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Legal Business Name | PROVIDENCE DENTAL LLC
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Dates
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Enumeration Date | 09/19/2018
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Last Update Date | 09/19/2018
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Provider Practice Location Address
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Address Line | 12450 E. COLONIAL DRIVE SUITE 124
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City | ORLANDO
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State | FL
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Zip | 32826
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Country | US
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Telephone | 407-635-0704
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Fax | 407-286-0439
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Provider Business Mailing Address
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Address Line | 12450 E. COLONIAL DRIVE SUITE 124
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City | ORLANDO
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State | FL
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Zip | 32826
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Country | US
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Telephone | 407-635-0704
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Fax | 407-286-0439
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Authorized Official
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Title or Position | CREDENTIALING CONSULTANT
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Name | NADIA KAHOOK
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Credential |
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Telephone | 954-446-5797
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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 |
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