Provider Demographics
NPI:1053662395
Name:SUMMIT PARK DENTAL, INC
Entity Type:Organization
Organization Name:SUMMIT PARK DENTAL, INC
Other - Org Name:LAKE QUALITY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:TA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-255-5538
Mailing Address - Street 1:440 CHINAHILL CT
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712
Mailing Address - Country:US
Mailing Address - Phone:352-430-0543
Mailing Address - Fax:352-430-0702
Practice Address - Street 1:723 CR 466
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-430-0543
Practice Address - Fax:352-430-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND14668122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty