Provider Demographics
NPI:1932111564
Name:SHALIMAR FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SHALIMAR FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-651-6700
Mailing Address - Street 1:1 ELEVENTH AVENUE
Mailing Address - Street 2:D-3
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579
Mailing Address - Country:US
Mailing Address - Phone:850-651-6700
Mailing Address - Fax:850-609-0796
Practice Address - Street 1:1 ELEVENTH AVENUE
Practice Address - Street 2:D-3
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579
Practice Address - Country:US
Practice Address - Phone:850-651-6700
Practice Address - Fax:850-609-0796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty