Provider Demographics
NPI:1255832440
Name:SPRING LAKE GROUP, PA
Entity Type:Organization
Organization Name:SPRING LAKE GROUP, PA
Other - Org Name:DENTAL CARE OF DR. PHILLIPS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:THAO
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-455-2471
Mailing Address - Street 1:125 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-3312
Mailing Address - Country:US
Mailing Address - Phone:408-455-2471
Mailing Address - Fax:
Practice Address - Street 1:7051 DR PHILLIPS BLVD STE 10
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5140
Practice Address - Country:US
Practice Address - Phone:407-345-1442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
572237939OtherPASSPORT
FLN250058777110OtherFLORIDA DRIVERS LICENSE