Provider Demographics
NPI:1114305414
Name:LIL DENTAL, P.A.
Entity Type:Organization
Organization Name:LIL DENTAL, P.A.
Other - Org Name:SORRENTO DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:CAMPUS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-492-7646
Mailing Address - Street 1:12385 SORRENTO RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-8664
Mailing Address - Country:US
Mailing Address - Phone:850-492-7646
Mailing Address - Fax:850-458-1601
Practice Address - Street 1:12385 SORRENTO RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-8664
Practice Address - Country:US
Practice Address - Phone:850-492-7646
Practice Address - Fax:850-458-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty