Provider Demographics
NPI:1609835453
Name:BADGER CENTER FOR MODERN DENTISTRY, PA
Entity Type:Organization
Organization Name:BADGER CENTER FOR MODERN DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:L. MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BADGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-370-0200
Mailing Address - Street 1:7009 DR PHILLIPS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5101
Mailing Address - Country:US
Mailing Address - Phone:407-370-0200
Mailing Address - Fax:407-370-0277
Practice Address - Street 1:7009 DR PHILLIPS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5101
Practice Address - Country:US
Practice Address - Phone:407-370-0200
Practice Address - Fax:407-370-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN139421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty