Provider Demographics
NPI:1285971846
Name:INTEGRATIVE ORAL HEALTH & WELLNESS, LLC
Entity type:Organization
Organization Name:INTEGRATIVE ORAL HEALTH & WELLNESS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:OUTLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-289-2881
Mailing Address - Street 1:250 PALM RIVER BLVD APT B102
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1102
Mailing Address - Country:US
Mailing Address - Phone:239-289-2881
Mailing Address - Fax:866-583-2067
Practice Address - Street 1:1187 8TH ST S UNIT 4
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-7306
Practice Address - Country:US
Practice Address - Phone:239-289-2881
Practice Address - Fax:866-583-2067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 135401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty