Provider Demographics
NPI:1295006641
Name:MDM OF LAKELAND PA
Entity Type:Organization
Organization Name:MDM OF LAKELAND PA
Other - Org Name:HIGHLANDS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-709-1903
Mailing Address - Street 1:701 S HOWARD AVE STE 106-386
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2473
Mailing Address - Country:US
Mailing Address - Phone:863-709-1903
Mailing Address - Fax:
Practice Address - Street 1:2153 E COUNTY ROAD 540A
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3794
Practice Address - Country:US
Practice Address - Phone:863-709-1903
Practice Address - Fax:863-709-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN188291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty