| Providence Dental Llc | |
|
12450 E. Colonial Drive Suite 124 Orlando FL 32826 | |
| (407) 635-0704 | |
| (407) 286-0439 |
| Full Name | Providence Dental Llc |
|---|---|
| Speciality | Dentist |
| Location | 12450 E. Colonial Drive Suite 124, Orlando, Florida |
| Authorized Official Name and Position | Nadia Kahook (CREDENTIALING CONSULTANT) |
| Authorized Official Contact | 9544465797 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Providence Dental Llc 12450 E. Colonial Drive Suite 124 Orlando FL 32826 Ph: (407) 635-0704 | Providence Dental Llc 12450 E. Colonial Drive Suite 124 Orlando FL 32826 Ph: (407) 635-0704 |
| NPI Number | 1407330145 |
|---|---|
| Provider Enumeration Date | 09/19/2018 |
| Last Update Date | 09/19/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1407330145 | NPI | - | NPPES |
| PENDING | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | (* (Not Available)) | Primary |
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