Provider Demographics
NPI:1063768372
Name:ALTAMONTE MALL DENTAL PA
Entity type:Organization
Organization Name:ALTAMONTE MALL DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-846-7171
Mailing Address - Street 1:451 E ALTAMONTE DR STE 1279
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-4617
Mailing Address - Country:US
Mailing Address - Phone:954-846-7171
Mailing Address - Fax:954-846-7170
Practice Address - Street 1:451 E ALTAMONTE DR STE 1279
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4617
Practice Address - Country:US
Practice Address - Phone:954-846-7171
Practice Address - Fax:954-846-7170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16377122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty