Provider Demographics
NPI:1821022526
Name:LIM, PETER (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 HOLSONBACK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5114
Mailing Address - Country:US
Mailing Address - Phone:386-274-0790
Mailing Address - Fax:386-274-0800
Practice Address - Street 1:1845 HOLSONBACK DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5114
Practice Address - Country:US
Practice Address - Phone:386-274-0790
Practice Address - Fax:386-274-0800
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN11833122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075608300Medicaid