Provider Demographics
NPI:1053488684
Name:PHOENIX ADVANCED INC
Entity Type:Organization
Organization Name:PHOENIX ADVANCED INC
Other - Org Name:HAINES CITY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:352-408-1400
Mailing Address - Street 1:35915 US HWY 27
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-3737
Mailing Address - Country:US
Mailing Address - Phone:863-422-8338
Mailing Address - Fax:863-422-5268
Practice Address - Street 1:35915 US HWY 27
Practice Address - Street 2:SUITE 2B
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-3737
Practice Address - Country:US
Practice Address - Phone:863-422-8338
Practice Address - Fax:863-422-5268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty