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General NPI Number Information
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NPI Number | 1629045489
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Entity Type | Organization
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Legal Business Name | AVALON DENTAL CLINIC PL
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Dates
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Enumeration Date | 03/01/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4272 AVALON BOULEVARD
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City | MILTON
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State | FL
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Zip | 32583-2858
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Country | US
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Telephone | 850-626-6100
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Fax | 850-626-6161
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Provider Business Mailing Address
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Address Line | 4272 AVALON BOULEVARD
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City | MILTON
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State | FL
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Zip | 32583-2858
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Country | US
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Telephone | 850-626-6100
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Fax | 850-626-6161
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANISSA MARIE RODRIQUEZ-OTTLEY
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Credential | DMD
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Telephone | 850-626-6100
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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 | DN15481
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License Number State | FL
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