Provider Demographics
NPI:1043917610
Name:ADA34, PA
Entity Type:Organization
Organization Name:ADA34, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:DORMESHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:917-847-6976
Mailing Address - Street 1:408 W INTERLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-0700
Mailing Address - Country:US
Mailing Address - Phone:863-465-2037
Mailing Address - Fax:
Practice Address - Street 1:408 W INTERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-0700
Practice Address - Country:US
Practice Address - Phone:863-465-2037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental