Provider Demographics
NPI:1932276565
Name:SUPRADENT INC
Entity Type:Organization
Organization Name:SUPRADENT INC
Other - Org Name:TRI DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:352-408-1400
Mailing Address - Street 1:18515 US HWY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6703
Mailing Address - Country:US
Mailing Address - Phone:352-383-5377
Mailing Address - Fax:352-383-2513
Practice Address - Street 1:18515 US HWY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6703
Practice Address - Country:US
Practice Address - Phone:352-383-5377
Practice Address - Fax:352-383-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty