Provider Demographics
NPI:1205591526
Name:MAHANT DENTAL LLC
Entity type:Organization
Organization Name:MAHANT DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALVORSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-686-3773
Mailing Address - Street 1:1411 CROMWELL DR APT SUITE
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-3017
Mailing Address - Country:US
Mailing Address - Phone:727-686-3773
Mailing Address - Fax:
Practice Address - Street 1:5396 FLOYD RD SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-2216
Practice Address - Country:US
Practice Address - Phone:770-941-7588
Practice Address - Fax:770-941-2119
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAHANT DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty