Provider Demographics
NPI:1619384955
Name:ENVISION DENTAL GROUP
Entity Type:Organization
Organization Name:ENVISION DENTAL GROUP
Other - Org Name:ICP DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:JOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-592-8520
Mailing Address - Street 1:4835 GABRIELLA LN
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8695
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3695 W BOYNTON BEACH BLVD
Practice Address - Street 2:SUITE #5
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-4516
Practice Address - Country:US
Practice Address - Phone:561-734-0505
Practice Address - Fax:561-734-0506
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VLADIMIR JOVIC DMD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DN 179521223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty