Provider Demographics
NPI:1376966598
Name:LADY LAKE DENTAL CARE, LLC
Entity Type:Organization
Organization Name:LADY LAKE DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:J
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-945-9545
Mailing Address - Street 1:13915 N US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8924
Mailing Address - Country:US
Mailing Address - Phone:352-753-6365
Mailing Address - Fax:352-753-9865
Practice Address - Street 1:13915 N US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8924
Practice Address - Country:US
Practice Address - Phone:352-753-6365
Practice Address - Fax:352-753-9865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13227122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty