Provider Demographics
NPI:1790855633
Name:CLERMONT CENTER FOR COMPREHENSIVE DENTISTRY
Entity Type:Organization
Organization Name:CLERMONT CENTER FOR COMPREHENSIVE DENTISTRY
Other - Org Name:COLONY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:J
Authorized Official - Last Name:ILKKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:352-787-5084
Mailing Address - Street 1:335 COLONY BLVD
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-6084
Mailing Address - Country:US
Mailing Address - Phone:352-753-3191
Mailing Address - Fax:352-753-3365
Practice Address - Street 1:335 COLONY BLVD
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-6084
Practice Address - Country:US
Practice Address - Phone:352-753-3191
Practice Address - Fax:352-753-3365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN92391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty