Provider Demographics
NPI:1952949141
Name:LUMINA DENTAL OF LUTZ, PA
Entity Type:Organization
Organization Name:LUMINA DENTAL OF LUTZ, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:IVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-381-5858
Mailing Address - Street 1:2945 GUINEVERE DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5916
Mailing Address - Country:US
Mailing Address - Phone:321-431-2208
Mailing Address - Fax:
Practice Address - Street 1:2425 BRUNELLO TRCE
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-7800
Practice Address - Country:US
Practice Address - Phone:813-381-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental