Provider Demographics
NPI:1033372958
Name:MOUNT DORA DENTAL & DENTURES
Entity Type:Organization
Organization Name:MOUNT DORA DENTAL & DENTURES
Other - Org Name:AFFORDABLE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOOK
Authorized Official - Middle Name:JA
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-385-1971
Mailing Address - Street 1:2781 W OLD HIGHWAY 441
Mailing Address - Street 2:#24A
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757
Mailing Address - Country:US
Mailing Address - Phone:352-385-1971
Mailing Address - Fax:325-729-2239
Practice Address - Street 1:2781 W OLD HIGHWAY 441
Practice Address - Street 2:#24A
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757
Practice Address - Country:US
Practice Address - Phone:352-385-1971
Practice Address - Fax:352-729-2239
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNT DORA DENTAL & DENTURES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-10
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14970122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002879200Medicaid