Provider Demographics
NPI:1629328620
Name:ST. LUKE'S FAMILY DENTISTRY, P.A.
Entity Type:Organization
Organization Name:ST. LUKE'S FAMILY DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WASIF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-366-9090
Mailing Address - Street 1:100 BURNSED PL
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6695
Mailing Address - Country:US
Mailing Address - Phone:407-366-9090
Mailing Address - Fax:
Practice Address - Street 1:100 BURNSED PL
Practice Address - Street 2:SUITE 1000
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-6695
Practice Address - Country:US
Practice Address - Phone:407-366-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15762122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty