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General NPI Number Information
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NPI Number | 1821623901
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Entity Type | Organization
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Legal Business Name | DESTIN DENTAL CARE LLC
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Dates
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Enumeration Date | 03/09/2020
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Last Update Date | 03/09/2020
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Provider Practice Location Address
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Address Line | 985 AIRPORT ROAD
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City | DESTIN
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State | FL
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Zip | 32541-2835
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Country | US
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Telephone | 850-837-6645
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Fax | 850-650-8553
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Provider Business Mailing Address
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Address Line | 985 AIRPORT ROAD
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City | DESTIN
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State | FL
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Zip | 32541-2835
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Country | US
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Telephone | 850-837-6645
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Fax | 850-650-8553
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Authorized Official
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Title or Position | OWNER
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Name | HENRY PAUL KELLUM
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Credential | D.D.S.
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Telephone | 850-837-6645
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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 |
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License Number State |
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