Provider Demographics
NPI:1770925661
Name:MIRROR IMAGE DENTISTRY
Entity type:Organization
Organization Name:MIRROR IMAGE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:NULTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:941-929-9332
Mailing Address - Street 1:2140 BISPHAM RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-5540
Mailing Address - Country:US
Mailing Address - Phone:941-929-9332
Mailing Address - Fax:941-929-7655
Practice Address - Street 1:2140 BISPHAM RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-5540
Practice Address - Country:US
Practice Address - Phone:941-929-9332
Practice Address - Fax:941-929-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00140151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty