=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487867099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR SUTINDER S KOHLI PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 11/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 464 S RIDGEWOOD AVE SUITE#1
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-4928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-255-8866
-----------------------------------------------------
Fax | 386-872-7532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 464 S RIDGEWOOD AVE SUITE#1
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-4928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-255-8866
-----------------------------------------------------
Fax | 386-872-7532
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SUTINDER SINGH KOHLI
-----------------------------------------------------
Credential | BDS,MS,FAGD
-----------------------------------------------------
Telephone | 386-255-8866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN13107
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------