Provider Demographics
NPI:1942384961
Name:LAKE WALES DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:LAKE WALES DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:JUNCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-678-3177
Mailing Address - Street 1:23871 HWY 27
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-7811
Mailing Address - Country:US
Mailing Address - Phone:863-678-3177
Mailing Address - Fax:863-678-3188
Practice Address - Street 1:23871 HWY 27
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-7811
Practice Address - Country:US
Practice Address - Phone:863-678-3177
Practice Address - Fax:863-678-3188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN118271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty