Provider Demographics
NPI:1740403492
Name:LAKE NONA DENTAL GROUP PLC
Entity Type:Organization
Organization Name:LAKE NONA DENTAL GROUP PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:YANTORNI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-277-1779
Mailing Address - Street 1:10429 MOSS PARK RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832
Mailing Address - Country:US
Mailing Address - Phone:407-277-1779
Mailing Address - Fax:
Practice Address - Street 1:10429 MOSS PARK RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832
Practice Address - Country:US
Practice Address - Phone:407-277-1779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN110001223G0001X
FLDN168031223G0001X
FLDN179851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty