Provider Demographics
NPI:1134322431
Name:SPRING LAKE DENTAL
Entity Type:Organization
Organization Name:SPRING LAKE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BHANJI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:863-585-3256
Mailing Address - Street 1:1192 HAVENDALE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-1360
Mailing Address - Country:US
Mailing Address - Phone:863-295-6555
Mailing Address - Fax:863-293-0810
Practice Address - Street 1:1192 HAVENDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-1360
Practice Address - Country:US
Practice Address - Phone:863-295-6555
Practice Address - Fax:863-293-0810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0014530261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental