Provider Demographics
NPI:1356734990
Name:TRINITY VILLAGE DENTAL, LLC
Entity type:Organization
Organization Name:TRINITY VILLAGE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JINCY
Authorized Official - Middle Name:KURUVILLA
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-372-9955
Mailing Address - Street 1:10720 STATE ROAD 54 STE 101
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2264
Mailing Address - Country:US
Mailing Address - Phone:727-372-9955
Mailing Address - Fax:727-372-7273
Practice Address - Street 1:10720 STATE ROAD 54 STE 101
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-2264
Practice Address - Country:US
Practice Address - Phone:727-372-9955
Practice Address - Fax:727-372-7273
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY VILLAGE DENTAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty