Provider Demographics
NPI:1295181790
Name:DENTAL ELEMENTS, PA
Entity Type:Organization
Organization Name:DENTAL ELEMENTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-847-8000
Mailing Address - Street 1:701 E OAK ST STE B
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4575
Mailing Address - Country:US
Mailing Address - Phone:407-847-8000
Mailing Address - Fax:
Practice Address - Street 1:701 E OAK ST STE B
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4575
Practice Address - Country:US
Practice Address - Phone:407-847-8000
Practice Address - Fax:407-847-6773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20281122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========1OtherNPI