Provider Demographics
NPI:1407330145
Name:PROVIDENCE DENTAL LLC
Entity Type:Organization
Organization Name:PROVIDENCE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:NADIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAHOOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-446-5797
Mailing Address - Street 1:12450 E. COLONIAL DRIVE SUITE 124
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826
Mailing Address - Country:US
Mailing Address - Phone:407-635-0704
Mailing Address - Fax:407-286-0439
Practice Address - Street 1:12450 E. COLONIAL DRIVE SUITE 124
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826
Practice Address - Country:US
Practice Address - Phone:407-635-0704
Practice Address - Fax:407-286-0439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid