Provider Demographics
NPI:1821623901
Name:DESTIN DENTAL CARE LLC
Entity Type:Organization
Organization Name:DESTIN DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-837-6645
Mailing Address - Street 1:985 AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2835
Mailing Address - Country:US
Mailing Address - Phone:850-837-6645
Mailing Address - Fax:850-650-8553
Practice Address - Street 1:985 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2835
Practice Address - Country:US
Practice Address - Phone:850-837-6645
Practice Address - Fax:850-650-8553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty