1558901751 NPI number — ROLLING ACRES DENTISTRY, PA

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 1558901751 NPI number — ROLLING ACRES DENTISTRY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROLLING ACRES DENTISTRY, PA
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:
1558901751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 NW 138TH TERRACE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
JONESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-332-3080
Provider Business Mailing Address Fax Number:
352-333-3729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
922 ROLLING ACRES ROAD
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
LADY LAKE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-259-8284
Provider Business Practice Location Address Fax Number:
352-259-8217
Provider Enumeration Date:
01/15/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NERIKAR
Authorized Official First Name:
VIVEK
Authorized Official Middle Name:
Authorized Official Title or Position:
DMD- DENTIST OWNER
Authorized Official Telephone Number:
904-553-4859

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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