Provider Demographics
NPI:1366078750
Name:DEBARY DENTISTRY LLC
Entity type:Organization
Organization Name:DEBARY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-303-1528
Mailing Address - Street 1:190 N CHARLES RICHARD BEALL BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2271
Mailing Address - Country:US
Mailing Address - Phone:386-668-2003
Mailing Address - Fax:
Practice Address - Street 1:190 N CHARLES RICHARD BEALL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2271
Practice Address - Country:US
Practice Address - Phone:386-668-2003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN19430OtherSTATE LICENSE