Provider Demographics
NPI:1225876717
Name:DOCTORS LAKE FAMILY DENTAL
Entity type:Organization
Organization Name:DOCTORS LAKE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:PADRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-264-6700
Mailing Address - Street 1:1665 EAGLE HARBOR PKWY
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4802
Mailing Address - Country:US
Mailing Address - Phone:904-264-6700
Mailing Address - Fax:904-264-6855
Practice Address - Street 1:1665 EAGLE HARBOR PKWY
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4802
Practice Address - Country:US
Practice Address - Phone:904-264-6700
Practice Address - Fax:904-264-6855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental