1124281977 NPI number — KENNETH L. MUNDY D.D.S., P.A.

Table of content: (NPI 1124281977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124281977 NPI number — KENNETH L. MUNDY D.D.S., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH L. MUNDY D.D.S., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124281977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4326 HIGHLAND PARK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33813-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-644-6418
Provider Business Mailing Address Fax Number:
863-644-6419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4326 HIGHLAND PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33813-1647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-644-6418
Provider Business Practice Location Address Fax Number:
863-644-6419
Provider Enumeration Date:
07/02/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MUNDY
Authorized Official First Name:
JUDY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
863-644-6418

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN6080 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)