Provider Demographics
NPI:1326698721
Name:KAITLIN DONOVAN DMD, PA
Entity Type:Organization
Organization Name:KAITLIN DONOVAN DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAITLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-837-3700
Mailing Address - Street 1:5380 STADIUM PKWY STE 119
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6001
Mailing Address - Country:US
Mailing Address - Phone:321-837-3700
Mailing Address - Fax:
Practice Address - Street 1:5380 STADIUM PKWY STE 119
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32955-6001
Practice Address - Country:US
Practice Address - Phone:321-837-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental