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General NPI Number Information
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NPI Number | 1578776357
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Entity Type | Organization
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Legal Business Name | GENERAL AND IMPLANT DENTISTRY AT THE LANDING
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 06/25/2008
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Provider Practice Location Address
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Address Line | 24600 S TAMIAMI TRL SUITE # 206
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City | BONITA SPRINGS
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State | FL
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Zip | 34134-7022
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Country | US
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Telephone | 239-949-8302
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Fax | 239-949-8374
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Provider Business Mailing Address
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Address Line | 24600 S TAMIAMI TRL SUITE # 206
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City | BONITA SPRINGS
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State | FL
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Zip | 34134-7022
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Country | US
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Telephone | 239-949-8302
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Fax | 239-949-8374
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KELLY M DAINIAK
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Credential | D.M.D.
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Telephone | 239-949-8302
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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 | DN15549
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License Number State | FL
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