Provider Demographics
NPI:1346681491
Name:WEKIVA PLACE, PA
Entity Type:Organization
Organization Name:WEKIVA PLACE, PA
Other - Org Name:WEKIVA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:OFFENBACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-869-7333
Mailing Address - Street 1:686 N HUNT CLUB BLVD
Mailing Address - Street 2:WEKIVA PLACE, SUITE 100
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-2218
Mailing Address - Country:US
Mailing Address - Phone:407-869-7333
Mailing Address - Fax:407-869-5720
Practice Address - Street 1:686 N HUNT CLUB BLVD
Practice Address - Street 2:WEKIVA PLACE, SUITE 100
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-2218
Practice Address - Country:US
Practice Address - Phone:407-869-7333
Practice Address - Fax:407-869-5720
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEKIVA PLACE, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN10359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty