Provider Demographics
NPI:1942556337
Name:AVALONDENTAL GROUP
Entity Type:Organization
Organization Name:AVALONDENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NGA
Authorized Official - Middle Name:K
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-281-1119
Mailing Address - Street 1:12950 E COLONIAL DR STE 124
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4609
Mailing Address - Country:US
Mailing Address - Phone:407-281-1119
Mailing Address - Fax:407-381-3711
Practice Address - Street 1:12950 E COLONIAL DR STE 124
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4609
Practice Address - Country:US
Practice Address - Phone:407-281-1119
Practice Address - Fax:407-381-3711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN179861223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003333500Medicaid