Provider Demographics
NPI:1316759905
Name:DESTINATION DENTAL GROUP PC
Entity type:Organization
Organization Name:DESTINATION DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-299-2692
Mailing Address - Street 1:2455 E SUNRISE BLVD STE 1204
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3115
Mailing Address - Country:US
Mailing Address - Phone:616-299-2692
Mailing Address - Fax:
Practice Address - Street 1:2455 E SUNRISE BLVD STE 1204
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3115
Practice Address - Country:US
Practice Address - Phone:616-299-2692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty