Provider Demographics
NPI:1124281977
Name:KENNETH L. MUNDY D.D.S., P.A.
Entity type:Organization
Organization Name:KENNETH L. MUNDY D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-644-6418
Mailing Address - Street 1:4326 HIGHLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1647
Mailing Address - Country:US
Mailing Address - Phone:863-644-6418
Mailing Address - Fax:863-644-6419
Practice Address - Street 1:4326 HIGHLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1647
Practice Address - Country:US
Practice Address - Phone:863-644-6418
Practice Address - Fax:863-644-6419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN6080122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty