Provider Demographics
NPI:1336459064
Name:DENTAL SPECIALISTS OF CENTRAL FLORIDA
Entity Type:Organization
Organization Name:DENTAL SPECIALISTS OF CENTRAL FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-453-7750
Mailing Address - Street 1:455 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4838
Mailing Address - Country:US
Mailing Address - Phone:321-453-7750
Mailing Address - Fax:321-453-4966
Practice Address - Street 1:455 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4838
Practice Address - Country:US
Practice Address - Phone:321-453-7750
Practice Address - Fax:321-453-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN191871223G0001X
FLDN190691223G0001X
FLDH17841124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty