Provider Demographics
NPI:1326470436
Name:MEDICAID DENTISTRY OF DAYTONA LLC
Entity Type:Organization
Organization Name:MEDICAID DENTISTRY OF DAYTONA LLC
Other - Org Name:DAYTONA PEDIATRIC DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MUBASHIR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAUDHRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-304-2677
Mailing Address - Street 1:1021 SOUTH RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114
Mailing Address - Country:US
Mailing Address - Phone:386-304-2677
Mailing Address - Fax:386-304-1899
Practice Address - Street 1:1021 SOUTH RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:386-304-2677
Practice Address - Fax:386-304-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL122300000X
FLDN137831223P0221X
FLDN187421223P0221X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty