1326470436 NPI number — MEDICAID DENTISTRY OF DAYTONA LLC

Table of content: (NPI 1326470436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326470436 NPI number — MEDICAID DENTISTRY OF DAYTONA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAID DENTISTRY OF DAYTONA LLC
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:
DAYTONA PEDIATRIC DENTISTRY
Provider Other Organization Name Type Code:
5
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:
1326470436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 SOUTH RIDGEWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-304-2677
Provider Business Mailing Address Fax Number:
386-304-1899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 SOUTH RIDGEWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-304-2677
Provider Business Practice Location Address Fax Number:
386-304-1899
Provider Enumeration Date:
07/31/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CHAUDHRY
Authorized Official First Name:
MUBASHIR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-304-2677

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: DN13783 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: DN18742 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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