Provider Demographics
NPI:1598138679
Name:113TH STREET SEMINOLE DENTAL LLC
Entity Type:Organization
Organization Name:113TH STREET SEMINOLE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-392-3900
Mailing Address - Street 1:8500 113TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4126
Mailing Address - Country:US
Mailing Address - Phone:727-392-3900
Mailing Address - Fax:
Practice Address - Street 1:8500 113TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4126
Practice Address - Country:US
Practice Address - Phone:727-392-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15686122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty