Provider Demographics
NPI:1376798280
Name:FLAGLER DENTAL ASSOCIATES PA
Entity Type:Organization
Organization Name:FLAGLER DENTAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:386-446-3883
Mailing Address - Street 1:30 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3808
Mailing Address - Country:US
Mailing Address - Phone:386-445-9318
Mailing Address - Fax:
Practice Address - Street 1:30 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3808
Practice Address - Country:US
Practice Address - Phone:386-445-9318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN169891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty