Provider Demographics
NPI:1265501084
Name:ADC VENTURES
Entity Type:Organization
Organization Name:ADC VENTURES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-994-8185
Mailing Address - Street 1:4041 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-1917
Mailing Address - Country:US
Mailing Address - Phone:850-994-8185
Mailing Address - Fax:
Practice Address - Street 1:4041 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1917
Practice Address - Country:US
Practice Address - Phone:850-994-8185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL484973OtherUNITED CONCORDIA I.D.
FL86052OtherBCBS I.D.