Provider Demographics
NPI:1780342352
Name:ORANGE PARK DENTISTRY
Entity type:Organization
Organization Name:ORANGE PARK DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-272-2438
Mailing Address - Street 1:784 BLANDING BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7724
Mailing Address - Country:US
Mailing Address - Phone:904-272-2438
Mailing Address - Fax:
Practice Address - Street 1:784 BLANDING BLVD STE 110
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7724
Practice Address - Country:US
Practice Address - Phone:904-272-2438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN19430OtherSTATE LICENSE
FLDN26279OtherSTATE LICENSE