Provider Demographics
NPI:1427389030
Name:PEDIATRIC DENTISTRY AT LAKE NONA
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY AT LAKE NONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUBISI
Authorized Official - Middle Name:OLUTOSIN
Authorized Official - Last Name:AINA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-737-7767
Mailing Address - Street 1:9161 NARCOOSSEE RD
Mailing Address - Street 2:101B
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-5764
Mailing Address - Country:US
Mailing Address - Phone:407-737-7767
Mailing Address - Fax:
Practice Address - Street 1:9161 NARCOOSSEE RD
Practice Address - Street 2:101B
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-5764
Practice Address - Country:US
Practice Address - Phone:407-737-7767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty