Provider Demographics
NPI:1487496337
Name:352-DENTIST, PA
Entity type:Organization
Organization Name:352-DENTIST, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:GERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-336-8478
Mailing Address - Street 1:13979 NW 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-9311
Mailing Address - Country:US
Mailing Address - Phone:352-284-9045
Mailing Address - Fax:
Practice Address - Street 1:809 HIGHWAY 466 STE C-102
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3909
Practice Address - Country:US
Practice Address - Phone:352-336-8478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental