Provider Demographics
NPI:1992823207
Name:KISSIMMEE DENTAL ASSOCIATES PA
Entity Type:Organization
Organization Name:KISSIMMEE DENTAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:THOMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-847-2103
Mailing Address - Street 1:324 PLEASANT STREET
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5732
Mailing Address - Country:US
Mailing Address - Phone:407-847-2103
Mailing Address - Fax:407-847-5042
Practice Address - Street 1:324 PLEASANT STREET
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5732
Practice Address - Country:US
Practice Address - Phone:407-847-2103
Practice Address - Fax:407-847-5042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL129751223G0001X
FL130331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty