Provider Demographics
NPI:1376946244
Name:PEDIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL GROUP
Other - Org Name:PEDIATRIC DENTAL GROUP WINTER PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLUBISI
Authorized Official - Middle Name:
Authorized Official - Last Name:AINA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-737-7767
Mailing Address - Street 1:5518 LAKE HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-1036
Mailing Address - Country:US
Mailing Address - Phone:407-737-7767
Mailing Address - Fax:407-737-0769
Practice Address - Street 1:5518 LAKE HOWELL RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-1036
Practice Address - Country:US
Practice Address - Phone:407-737-7767
Practice Address - Fax:407-737-0769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty