=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942556337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVALONDENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2012
-----------------------------------------------------
Last Update Date | 08/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12950 E COLONIAL DR STE 124
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32826-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-281-1119
-----------------------------------------------------
Fax | 407-381-3711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12950 E COLONIAL DR STE 124
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32826-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-281-1119
-----------------------------------------------------
Fax | 407-381-3711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | MRS. NGA K VAN
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 407-281-1119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number | DN17986
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------