Provider Demographics
NPI:1508522368
Name:DAVENPORT DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:DAVENPORT DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAMORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-586-4500
Mailing Address - Street 1:2213 NORTH BLVD W
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-8990
Mailing Address - Country:US
Mailing Address - Phone:863-256-3636
Mailing Address - Fax:
Practice Address - Street 1:2213 NORTH BLVD W
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8990
Practice Address - Country:US
Practice Address - Phone:863-256-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental