Provider Demographics
NPI:1780996181
Name:ASPEN DENTAL GROUP, PA
Entity type:Organization
Organization Name:ASPEN DENTAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:386-752-2336
Mailing Address - Street 1:1788 SW BARNETT WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6953
Mailing Address - Country:US
Mailing Address - Phone:386-752-2336
Mailing Address - Fax:386-752-8601
Practice Address - Street 1:1788 SW BARNETT WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6953
Practice Address - Country:US
Practice Address - Phone:386-752-2336
Practice Address - Fax:386-752-8601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN140781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty