Provider Demographics
NPI:1710580014
Name:IVORY DENTAL GROUP LLC
Entity Type:Organization
Organization Name:IVORY DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINA
Authorized Official - Middle Name:
Authorized Official - Last Name:YU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-386-9106
Mailing Address - Street 1:9209 SMITHIES ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-3840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4270 ALOMA AVE STE 130
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-9366
Practice Address - Country:US
Practice Address - Phone:407-813-1788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty