Provider Demographics
NPI:1225427818
Name:PERDIDO BAY DENTAL PA
Entity Type:Organization
Organization Name:PERDIDO BAY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SLAVOLJUB
Authorized Official - Middle Name:
Authorized Official - Last Name:DJURIC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-542-4428
Mailing Address - Street 1:12950 LILLIAN HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-8423
Mailing Address - Country:US
Mailing Address - Phone:850-542-4428
Mailing Address - Fax:850-607-7515
Practice Address - Street 1:12950 LILLIAN HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-8423
Practice Address - Country:US
Practice Address - Phone:850-542-4428
Practice Address - Fax:850-607-7515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12887122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty