Provider Demographics
NPI:1629045489
Name:AVALON DENTAL CLINIC PL
Entity Type:Organization
Organization Name:AVALON DENTAL CLINIC PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANISSA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RODRIQUEZ-OTTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-626-6100
Mailing Address - Street 1:4272 AVALON BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-2858
Mailing Address - Country:US
Mailing Address - Phone:850-626-6100
Mailing Address - Fax:850-626-6161
Practice Address - Street 1:4272 AVALON BOULEVARD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-2858
Practice Address - Country:US
Practice Address - Phone:850-626-6100
Practice Address - Fax:850-626-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN154811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty