1457604522 NPI number — ADVANCED DENTAL CARE PALM COAST

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457604522 NPI number — ADVANCED DENTAL CARE PALM COAST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED DENTAL CARE PALM COAST
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:
1457604522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 PINE CONE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32137-8685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 PINE CONE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32137-8685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-447-6550
Provider Business Practice Location Address Fax Number:
386-986-4565
Provider Enumeration Date:
10/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP INSURANCE PLAN MANAGEMENT
Authorized Official Telephone Number:
727-726-1611

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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