Provider Demographics
NPI:1124619556
Name:LTC DENTAL
Entity type:Organization
Organization Name:LTC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-375-3003
Mailing Address - Street 1:4060 S LAKE DR APT 4
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-5256
Mailing Address - Country:US
Mailing Address - Phone:407-375-3003
Mailing Address - Fax:800-863-5373
Practice Address - Street 1:4060 S LAKE DR APT 4
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-5256
Practice Address - Country:US
Practice Address - Phone:407-375-3003
Practice Address - Fax:800-863-5373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental