Provider Demographics
NPI:1245491984
Name:DEFUNIAK SPRINGS FAMILY DENTAL
Entity type:Organization
Organization Name:DEFUNIAK SPRINGS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:CARSON
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-892-0866
Mailing Address - Street 1:746 BALDWIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435
Mailing Address - Country:US
Mailing Address - Phone:850-892-0866
Mailing Address - Fax:850-892-4280
Practice Address - Street 1:746 BALDWIN AVENUE
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435
Practice Address - Country:US
Practice Address - Phone:850-892-0866
Practice Address - Fax:850-892-4280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN175321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty