Provider Demographics
NPI:1598979122
Name:CARLA TALAVERA-JORDAN D.M.D., P.A.
Entity Type:Organization
Organization Name:CARLA TALAVERA-JORDAN D.M.D., P.A.
Other - Org Name:SOUTH LAKE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:TALAVERA-JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-242-0912
Mailing Address - Street 1:533 CAGAN PARK AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-4867
Mailing Address - Country:US
Mailing Address - Phone:352-242-0912
Mailing Address - Fax:
Practice Address - Street 1:533 CAGAN PARK AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714
Practice Address - Country:US
Practice Address - Phone:352-242-0912
Practice Address - Fax:352-242-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2011-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 164541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty