Provider Demographics
NPI:1477895464
Name:LAKE MYRTLE CENTER FOR ADVANCED DENTISTRY
Entity Type:Organization
Organization Name:LAKE MYRTLE CENTER FOR ADVANCED DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,
Authorized Official - Phone:863-662-9973
Mailing Address - Street 1:2016 US HIGHWAY 92 W
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-3921
Mailing Address - Country:US
Mailing Address - Phone:863-662-9973
Mailing Address - Fax:863-875-5736
Practice Address - Street 1:2016 US HIGHWAY 92 W
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-3921
Practice Address - Country:US
Practice Address - Phone:863-662-9973
Practice Address - Fax:863-875-5736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN166431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty