Provider Demographics
NPI:1851557078
Name:IMPERIAL BOULEVARD MANAGEMENT,LLC
Entity Type:Organization
Organization Name:IMPERIAL BOULEVARD MANAGEMENT,LLC
Other - Org Name:LAKELAND PEDIATIRC DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TURSTEE
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-644-4739
Mailing Address - Street 1:225 IMPERIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4612
Mailing Address - Country:US
Mailing Address - Phone:863-644-4739
Mailing Address - Fax:863-644-1333
Practice Address - Street 1:225 IMPERIAL BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4612
Practice Address - Country:US
Practice Address - Phone:863-644-4739
Practice Address - Fax:863-644-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1190925122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty