Provider Demographics
NPI:1588091250
Name:ST. LUKE'S DENTAL, PLC.
Entity type:Organization
Organization Name:ST. LUKE'S DENTAL, PLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAHBA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-909-1555
Mailing Address - Street 1:1908 LAND O LAKES BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-2914
Mailing Address - Country:US
Mailing Address - Phone:813-909-1555
Mailing Address - Fax:813-909-1556
Practice Address - Street 1:1908 LAND O LAKES BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-2914
Practice Address - Country:US
Practice Address - Phone:813-909-1555
Practice Address - Fax:813-909-1556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15339261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental