Provider Demographics
NPI:1659677714
Name:MJ DENTAL SERVICES, PA
Entity Type:Organization
Organization Name:MJ DENTAL SERVICES, PA
Other - Org Name:MITESH JIVAN DMD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITESH
Authorized Official - Middle Name:
Authorized Official - Last Name:JIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-383-2959
Mailing Address - Street 1:2230 WEST OLD HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-3508
Mailing Address - Country:US
Mailing Address - Phone:352-383-2959
Mailing Address - Fax:352-735-3355
Practice Address - Street 1:2230 WEST OLD HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-3508
Practice Address - Country:US
Practice Address - Phone:352-383-2959
Practice Address - Fax:352-735-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18726122300000X
FLDN63601223G0001X
FLDH5118124Q00000X
FLDH15460124Q00000X
FLDH5702124Q00000X
FL106953126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty