Provider Demographics
NPI:1811388804
Name:KUSH DENTAL LLC
Entity Type:Organization
Organization Name:KUSH DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGARO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-636-7602
Mailing Address - Street 1:1012 STATE ROAD 436
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5722
Mailing Address - Country:US
Mailing Address - Phone:407-636-7602
Mailing Address - Fax:407-636-7604
Practice Address - Street 1:1012 STATE ROAD 436
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5722
Practice Address - Country:US
Practice Address - Phone:407-636-7602
Practice Address - Fax:407-636-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL606214261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental