Provider Demographics
NPI:1205067725
Name:KIDS ONLY DENTAL PLACE
Entity type:Organization
Organization Name:KIDS ONLY DENTAL PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:N
Authorized Official - Last Name:MIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PA
Authorized Official - Phone:352-335-7777
Mailing Address - Street 1:5209 SW 91ST DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-3028
Mailing Address - Country:US
Mailing Address - Phone:352-335-7777
Mailing Address - Fax:352-371-3430
Practice Address - Street 1:5209 SW 91ST DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-3028
Practice Address - Country:US
Practice Address - Phone:352-335-7777
Practice Address - Fax:352-371-3430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071755000Medicaid
FL986885OtherUNITED CONCORDIA
FL36580OtherBCBS OF FL