Provider Demographics
NPI:1386009017
Name:SUNDANCE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SUNDANCE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:OSORIO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-837-3700
Mailing Address - Street 1:5380 STADIUM PKWY
Mailing Address - Street 2:SUITE 119
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6001
Mailing Address - Country:US
Mailing Address - Phone:321-837-3700
Mailing Address - Fax:
Practice Address - Street 1:5380 STADIUM PKWY
Practice Address - Street 2:SUITE 119
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32955-6001
Practice Address - Country:US
Practice Address - Phone:321-837-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN187401223G0001X
FLDN171671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty