Provider Demographics
NPI:1235697707
Name:PEDIATRIC DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUBISI
Authorized Official - Middle Name:
Authorized Official - Last Name:ALNA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-737-7767
Mailing Address - Street 1:9161 NARCOOSSEE RD
Mailing Address - Street 2:STE 101B
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827
Mailing Address - Country:US
Mailing Address - Phone:407-737-7767
Mailing Address - Fax:407-737-0769
Practice Address - Street 1:12601 NARCOOSSEE RD
Practice Address - Street 2:UNITE 100A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832
Practice Address - Country:US
Practice Address - Phone:407-737-7767
Practice Address - Fax:407-737-0769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty