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General NPI Number Information
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NPI Number | 1871783787
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Entity Type | Organization
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Legal Business Name | FOREST LAKE DENTAL GROUP
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Dates
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Enumeration Date | 07/26/2007
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Last Update Date | 01/14/2016
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Provider Practice Location Address
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Address Line | 628 NORTH BEAR LAKE ROAD
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City | APOPKA
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State | FL
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Zip | 32703
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Country | US
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Telephone | 407-862-1231
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Fax | 407-862-1222
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Provider Business Mailing Address
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Address Line | 628 NORTH BEAR LAKE ROAD
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City | APOPKA
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State | FL
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Zip | 32703
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Country | US
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Telephone | 407-862-1231
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Fax | 407-862-1222
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARLOS MANUEL MARTIN
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Credential | DDS
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Telephone | 407-862-1231
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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 | 14761
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License Number State | FL
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