Provider Demographics
NPI:1417407891
Name:ADVANCED PARK DENTAL
Entity Type:Organization
Organization Name:ADVANCED PARK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MITESH
Authorized Official - Middle Name:
Authorized Official - Last Name:JIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-628-0200
Mailing Address - Street 1:329 N PARK AVE
Mailing Address - Street 2:SUITE #360
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-7408
Mailing Address - Country:US
Mailing Address - Phone:407-628-0220
Mailing Address - Fax:
Practice Address - Street 1:329 N PARK AVE
Practice Address - Street 2:SUITE #360
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-7408
Practice Address - Country:US
Practice Address - Phone:407-628-0220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18726122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty