Provider Demographics
NPI:1629662341
Name:SUMMERLAND DENTAL PROFESSIONAL ASSOCIATION
Entity Type:Organization
Organization Name:SUMMERLAND DENTAL PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYCOLIZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:305-745-1522
Mailing Address - Street 1:PO BOX 420212
Mailing Address - Street 2:
Mailing Address - City:SUMMERLAND KEY
Mailing Address - State:FL
Mailing Address - Zip Code:33042-0212
Mailing Address - Country:US
Mailing Address - Phone:305-745-1522
Mailing Address - Fax:
Practice Address - Street 1:24986 OVERSEAS HWY
Practice Address - Street 2:
Practice Address - City:SUMMERLAND KEY
Practice Address - State:FL
Practice Address - Zip Code:33042-4612
Practice Address - Country:US
Practice Address - Phone:305-745-1522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMERLAND DENTAL PROFESSIONAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment