Provider Demographics
NPI:1700411857
Name:IMAGINE ORTHODONTIC STUDIO PLLC
Entity Type:Organization
Organization Name:IMAGINE ORTHODONTIC STUDIO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAIYAL
Authorized Official - Middle Name:
Authorized Official - Last Name:POPAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-758-5424
Mailing Address - Street 1:3595 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3595 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4860
Practice Address - Country:US
Practice Address - Phone:727-743-8307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-10
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty