Provider Demographics
NPI:1740568187
Name:HOUSE OF COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:HOUSE OF COSMETIC DENTISTRY
Other - Org Name:FORTUNE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-348-2002
Mailing Address - Street 1:2324 FORTUNE RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-3993
Mailing Address - Country:US
Mailing Address - Phone:407-348-2002
Mailing Address - Fax:407-348-2009
Practice Address - Street 1:2324 FORTUNE RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-3993
Practice Address - Country:US
Practice Address - Phone:407-348-2002
Practice Address - Fax:407-348-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16387122300000X
FLDN165861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty