Provider Demographics
NPI:1558991232
Name:LAKELAND DENTAL PROFESSIONALS PLLC
Entity Type:Organization
Organization Name:LAKELAND DENTAL PROFESSIONALS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYOR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-470-8554
Mailing Address - Street 1:310 E HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1727
Mailing Address - Country:US
Mailing Address - Phone:863-646-8511
Mailing Address - Fax:
Practice Address - Street 1:310 E HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1727
Practice Address - Country:US
Practice Address - Phone:863-646-8511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1699189803OtherNPI
FL1144636788OtherNPI
1922157619OtherNPI