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General NPI Number Information
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NPI Number | 1780341099
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Entity Type | Organization
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Legal Business Name | LTC DENTAL II LLC
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Dates
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Enumeration Date | 11/22/2021
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Last Update Date | 11/22/2021
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Provider Practice Location Address
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Address Line | 4060 S LAKE DR APT 4
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City | SAINT FRANCIS
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State | WI
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Zip | 53235-5256
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Country | US
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Telephone | 407-375-3003
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Fax | 800-863-5373
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Provider Business Mailing Address
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Address Line | 4060 S LAKE DR APT 4
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City | SAINT FRANCIS
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State | WI
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Zip | 53235-5256
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Country | US
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Telephone | 407-375-3003
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Fax | 800-863-5373
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Authorized Official
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Title or Position | CHIEF EXECUTE OFFICER
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Name | TARA ROBINSON
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Credential |
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Telephone | 407-375-3003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number |
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License Number State |
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Taxonomy #2
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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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