Provider Demographics
NPI:1316348956
Name:SOUTH ORLANDO DENTAL CENTER
Entity type:Organization
Organization Name:SOUTH ORLANDO DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRALYS
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHARDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:407-857-9888
Mailing Address - Street 1:8309 PRESTBURY DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-6318
Mailing Address - Country:US
Mailing Address - Phone:321-422-9993
Mailing Address - Fax:
Practice Address - Street 1:11222 S ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-9428
Practice Address - Country:US
Practice Address - Phone:407-857-9888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18752261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental