Provider Demographics
NPI:1538628219
Name:LAKE NONA ENDODONTICS PA
Entity type:Organization
Organization Name:LAKE NONA ENDODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-204-6471
Mailing Address - Street 1:743 STIRLING CENTER PL STE 1701
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5712
Mailing Address - Country:US
Mailing Address - Phone:407-574-2539
Mailing Address - Fax:407-674-2539
Practice Address - Street 1:13571 NARCOOSSEE ROAD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832
Practice Address - Country:US
Practice Address - Phone:407-574-4271
Practice Address - Fax:407-674-2539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-13
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty